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NPF Responses – Health

The National Policy Forum’s consultation on Health and Social care is set in the firm context of an underfunded health and social care service. This is correct. However, the document is insufficiently clear about the need to reverse the general direction of travel and fails to give enough indication about Labour’s alternatives. In the rest of this article I have tried to combine two articles in one both commenting on and proposing changes to the draft. Most of what follows consists of suggested amendments/additions to the draft. The passages in italics are my comments on the draft.

Every organisation has scope for some savings, reform and doing things better including the NHS. But this should not obscure the fundamental truth that the funding crisis in  UK health and social care is also part of an ideological drive to reduce the role of the state as all our key public services. Linked to this is the equally ideologically driven policy of diversifying public service provision to include the corporate and for-profit sector in care delivery. And as our public services come under more and more pressure, those who can afford it will resort to “better” private care provision and so create further momentum to undermine  the social solidarity that is at the heart of our welfare state and public sector.

In majoring on the financial crisis that faces the NHS and Social Care, the consultation document is short on setting out the principles for how a future Labour government would respond. Indeed it recognises this insofar as it explicitly asks for consultation responses on how financial stability can be restored. This has got to be more than steadying the ship as our demographics and advances in health care will require an ever increasing share of our GDP.

Labour recognises that it is not enough to criticise the evident financial crisis engulfing the NHS and social care. It therefore takes as an immediate task to use all the expertise available to it through service users, health workers and analysts, to evaluate the changing health needs of the population in the immediate, medium and long term. Where this points to the need for an increased proportion of GDP to be devoted to health and social care this must be clearly stated. This will require the Policy Forum to call on all the advice it needs to spell out the consequent rebalancing of public expenditure to deliver decent health and care standards.

Labour recognises that increasing costs of health care are not all driven by high technology and expensive drugs. Health and social care must, above all else, be a “people looking after people” service. We have seen years of an effective wages freeze for staff. And if we are going to provide better personal care with dignity we need more, better paid, better trained staff

The last Labour government succeeded in bringing British health and social care in line with OECD averages. Between 1948 to 1999 there was a real terms annual funding increase in the English NHS of 3%. The additional Labour spending that took place between 1999 and 2010 saw this real term increase grow to 4% (Baker Report; Kings Fund 2014). In view of the serious under-resourcing that we are now experiencing this gives us some idea of the minimum yearly funding targets a future Labour government needs to achieve following an initial boost to catch up on lost time. Labour will ask its health team to make as precise an evaluation of the funding needs as is possible during the coming year.

The draft document expresses concern that hospital savings required by STPs across England will have a knock-on effect on community and primary care services. This will inevitably be the case but there is a risk that posing the question in this way reflects a failure to emphasise that strong and resilient community and primary care services are indispensable to sustaining our hospital service. Our hospital sector will always be under unacceptable pressures if our community services cannot manage chronic and complex conditions effectively in an readily accessible, caring and dignified environment.

It is key to providing an efficient and effective health service that it integrates health provision with care services. There needs to be greater integration of services both between hospitals and the community and also between health and social care. There can be endless arguments as to what an integrated service is but the litmus test must be to deliver a service that the patient and service user does not notice the difference in care no matter what body or agency is delivering it?

Structures and organisational boundaries must not be visible to users but  where they are at odds with the policy intention of “integrated services”, then they must be looked at. It is hard to deliver a seamless service when one is comprehensive and free at the point of use while the other is conditional on a complex web of means testing and eligibility criteria. This may not have been such a big issue when Atlee’s government founded our modern welfare state but as our population gets older and more fragile these tensions are proving real barriers to integrated, coherent care. Labour will analyse the detail of the major barriers to providing integrated services and will propose means by which they can be removed and any cost implications that this might give rise to.

Very many people think their social contract with our welfare state looks after them from the cradle to the grave. This may be overwhelmingly true for the NHS but it certainly is not true for social care. Social care is an area where different parts of the UK have taken different paths. England might usefully learn from that experience. The Commission will make it a part of its task in the coming year to report on what these diverse experiences can tell us and how they can inform health and care policy generally. (Commission for the Provision of Quality Care in Scotland – Kelly Report, Scottish Labour Party 2014, Making Prudent Health Care Happen – Welsh Government. http.www.prudenthealthcare.org.uk/).

A key delivery agency must be the patient themselves, their carers, their families and indeed the wider community. This is not about passing the buck to the patient or their family. The management of chronic, complex illness or the decisions as to how it affects patients are not just for highly trained professional experts. The jargon phrase is “co-production” to describe this process. But unless we develop a health and social care service that can embrace the principle of co-production we will have a failing system that tries to do things to patients and service users rather than with them.

A significant omission  from the consultation document overall is the absence  of  an awareness of the the importance of partnership and co-operation.

Since the Thatcherite late 1980s we have seen a relentless drive to commercialise the NHS and social care though the terrible twins of competition and division. Almost a quarter century later the futility of this approach is becoming ever more evident.

In Scotland and Wales the internal market has been officially abolished but it remains in England. But even here in many of the STP plans, as well as initiatives such as “Devo Manc”, the requiem bells for commercialisation, competition and division are tolling, albeit muffled to avoid too many noticing. It is now time for Labour to acknowledge the failure of the “market model” and will seek to re-build our NHS on the principals of partnership and co-operation.

All consultation documents ask questions but in this instance the questions provide more clarity than the document’s main commentary. They seem to hint at certain directions of travel which the main text shies away from overtly stating. While this gives respondents a wider latitude to formulate policy though their replies, it is disappointing that significant blanks still need to be filled.

The central message of the consultation document of a seriously under-funded health and social care service is unquestionably true.

We know what the international bench marks for health and social care spending are and we also know what the historical spending requirements have been. They must be the point of departure for any serious discussion on how care is to be funded.

But money on its own is not a cure-all. Labour is committed to changing the way our  health and care provision is delivered. We recognise that a public funded, publicly delivered service based on the principles of partnership and co-operation will be the way forward.

16 Comments

  1. JohnP says:

    Great article, Brian.

  2. Mervyn Hyde says:

    “But money on its own is not a cure-all. Labour is committed to changing the way our  health and care provision is delivered. We recognise that a public funded, publicly delivered service based on the principles of partnership and co-operation will be the way forward”.

    Sadly this is the sort of Neo-Liberal language that we must ditch.

    The NHS has been abolished. “It’s just another Industry” according to Alan Milburn and that is precisely what the Lansley Bill set out to achieve.

    For those not conversant with it; the NHS Bill currently going through parliament is the only game in town, it total rejects the private sector and brings social care back into the fold. In short it renationalises the NHS and social care.

    Clearly when I hear people repeat like parrots that money isn’t the total answer, that throwing money at it won’t solve all the problems, I ask why then did the Tories deliberately underfund the NHS? The answer is obvious, to deliberately cripple it.

    Of course the NHS has been underfunded, privatised and deliberately undermined, the Francis report was widely reported as highlighting over 1400 deaths in the Mid Staffs hospital in order to discredit the NHS, but in fact for those that have read the report from front to back know, you will not find one death mentioned in the report as those were statistical projections and not facts, but the media deliberately leaked those statistics which were not even mentioned in the report.

    To say that Neo-Liberalism is fundamentally dismantling the state should appear obvious to any thinking person in this country and our NHS is at the heart of this agenda, the most successful health system in the world is being dismantled before our eyes and yet people still do not understand the full implications as to what is happening.

    I think most think, that the Tories will keep it free at the point of use, which has overlooked the fact that Hunt admitted to a public accounts committee, that he has already been involved in discussions with Kaiser Permanente an American Health Insurance Company. Needless to say he has in his words, been involved with American Private health companies discussing new ways to provide better health care. The irony of it, he takes advice from the worst health care organisations ignoring that the NHS is already the top system in the world. Noting that 40% of Americans either can’t or have poor health insurance cover, and rely on charity hospitals for treatment.

    Dr Allyson Pollock is the academic that along with a solicitor drafted the NHS Bill, and this short video explains in detail why the NHS is successful and why the private sector has no place in medicine.

    http://tedxexeter.com/2014/05/06/allyson-pollock-privatisation-of-the-nhs/

    1. David Pavett says:

      Mervyn, Labour’s traditional position on issues of social provision is that more of it would be a good thing. The problem with this is that social provision, let’s say in education, is not just a question of quantity but also a question of quality. Therefore simply spending more is generally not a sufficient response (even though it may well be necessary). To suggest that questioning spending more as a panacea is a concession to neo-liberalism seems to me to be the crudest form of left politics

      What we need is rather a critique of the current system and for a transformation of its culture (including democratic as opposed to narrow managerial culture) to be part of the package, along with increased resources. This clearly requires are far greater effort from the left than simply to call for spending more but that is no excuse for not doing it.

      That is what Brian Gibbons proposes and on that basis I find his contribution extremely helpful.

      1. Mervyn Hyde says:

        David, Society constantly seeks improvement as a matter of course, to say that we should look at alternatives and properly analyse all aspects of social provision is a natural given.

        What we have seen in the video does exactly that in fact and it doesn’t take a rocket scientist to work out that the inherent pitfalls in the private sector models plainly makes the case for public provision.

        This OECD data sheet from 2001 shows how our NHS lead the world as the cheapest, most comprehensive, efficient health care system in the world.

        http://content.healthaffairs.org/content/23/3/10/T1.expansion

        It is the politicians that are destroying our NHS not the system itself, and yes we should fund it to whatever it needs, it is there to serve people, people don’t deliberately fall ill in order to create a market in health.

        We have the money to properly fund the NHS, it’s currently being deliberately understaffed and under-resourced those are the real issues, followed renationalisation, let our professional doctors run the health service as it did in 2001, then we can all get on with our lives safe in the knowledge that we will once again have the finest health service in the world, that also goes for the rest of public services.

        1. David Pavett says:

          I am sorry Martin but this just not address my point. The managerial and financial structures of the NHS are awful as is its built in resistance to constructive criticism. Those things need to change too. It is not just a question of spending more money, as Brian Gibbons says. To respond by saying that this is “the neo-liberal language we must ditch” is really not helpful. He is not saying that we cannot afford to provide a high quality public health service, quite the contrary.

          1. David,
            A fresh conceptual approach might involve focusing attention on the value-creation chain in healthcare rather than on costs, efficiency and revenue. There are three questions that might be attempted.
            The first is: what value does healthcare create? One answer might be: healthier and happier people. These are subjective and can’t be quantified which suggests that attempts to justify spending on healthcare by quantifying outputs is misleading and likely toresult in resource misallocation (which could also be caused by data manipulation by the government, managers and service providers).
            The second is: how is value created in healthcare? The answer is simpler: through the constructive interaction between and among those seeking healthcare services and those providing them (including nurses, paramedics, ambulance workers, administrators etc).
            This leads on to the third and crucial question: how can we increase value-creation at any level of resourcing for the healthcare sector?
            The answer is: by removing all obstacles to constructive interaction among those seeking and providing healthcare services.
            The easiest way to increase healthcare value creation is by providing the information patients and those helping them need to make good healthcare choices.
            Happily, the NHS has established an integrated database containing all information created in interactions involving GPs. No other country on earth has this information.
            Work is now proceeding on integrating this information with data flowing from hospitals, which covers the clinical patient pathway from admission to release.
            Once this is done, the NHS will have the most valuable healthcare database on the planet. This information cannot be sold commercially because it would involve breaching patient confidentiality or used commercially for the same reason. More importantly, this information (once it’s properly structured and managed) will allow the NHS radically to increase value creation at any funding level. That’s because it will have the most valuable health risk actuarial database on earth (and one that would be worth at least £50bn to a for profit business). But the healthcare value creation it would allow could be worth several times this and (depending on your subjective view) probably sufficient to validate the £120bn+ NHS budget in 2016/17.
            Seen from this perspective, investment in the NHS health information database (which can only be complete if people are not charged for visiting GPs or attending hospitals) is entirely self-resourcing. Once you factor in the impact on good and service production of happy and healthy people, it will deliver increases in social surplus value. These conclusions can’t be reached using conventional price-based ways of measuring healthcare inputs and outputs.

          2. David Pavett says:

            @Edmund O’Sullivan, April 1, 2017.
            I am not sure how any of what you write is a comment on anything I wrote.
            I think you are wrong to think that patient confidentiality prevent NHS data being sold once suitably (or even unsuitably) anonymised. I also think you are seriously confusing different meanings of the word “values”. I think that the arguments about the data collection paying for itself don’t make much sense. How would it “pay for itself” if it is not for sale?

      2. David,
        It’s about a different way of thinking about healthcare which focuses on the key issue: value creation rather than costs and revenues.
        The NHS at present faces problems from patients who object to information given to their GPs being centrally captured (perhaps there needs to be an explicit statement by the NHS that information used by patients will be stored and used exclusively by the NHS). The anonymisation would have to be explicitly assented to and wouldn’t everyone object if there was an even outside chance their data in any form could be shared with/sold to the private sector?
        Structured health data encompassing the entire UK population is almost infinitely valuable. Beneficiaries of the NHS don’t know this because the value of the data hasn’t been capitalised as an asset or converted into an income stream precisely because it’s not for sale and therefore hasn’t been priced. A valuation exercise based on how much revenue the NHS would make if were privately owned would, I believe, show that it is worth much more than it costs. An explicit ban on NHS patient data being shared with for-profit organisations would also help.

  3. Bill says:

    And as our public services come under more and more pressure, those who can afford it will resort to “better” private care provision and so create further momentum to undermine the social solidarity that is at the heart of our welfare state and public sector.

    This is the most pertinent part of the article and how the NHS will be reduced to a ‘PDSA’ level of service.Most working class people with even moderate incomes will buy into private provision.

    If we have another Conservative Government people will have voted to end the NHS and its ethos.So far nothing Labour has said or vaguely proposed has resonated with the public.

  4. Bazza says:

    The NHS was a brilliant socialist reform for working people but of course capital benefitted too, getting all these healthy workers for free, and capital wants everything for free.
    Yet although we all contribute via National Insurance it is free at the point of use when we need it.
    A doctor and health campaigner summed it up well: if you need heart surgery in the UK it is free, in the US it could cost you 260,000 dollars!
    But good points are made about funding and perhaps we may need to think smarter!
    It is like there is a giant cooking pot full with our favourite ingredients which we all love but it is leaking all over the place but we just continuously keep topping it up!
    The leaks are: the private sector, the market type accounting system, the huge drugs bill, the huge agency staff and locum bill, the huge costs from PFI, and I am sure there are more that those on the front line could add, and we need to address each in turn.
    For example kick the private sector out, no more PFI, take the pharmaceutical industry into democratic public ownership and save the NHS billions (as well as enabling research into “less profitable” conditions) plus stop patients with serious conditions being robbed of a few precious extra years of life because of the market!
    Then after we do all this and need more money then tax the rich, corporations, close tax havens, end tax dodging etc.
    Oh and I am old enough to remember the old and pretty democratic Community Health Councils which were pretty popular before the advent of New Labour, perhaps we should bring something democratic and similar to them back?
    Perhaps we have a top down NHS run by numerous managers (i think I read there were 100 senior NHS executives earning more than The Prime Minister) and I remember the famous quote by Nye Bevan that he “had to stuff the consultants mouths with gold” to bring them on board.
    So perhaps we need the reverse – more of a bottom up community/health worker/patient-led approach?
    And remember the Tories originally voted against the formation of the NHS and it is never ever safe in their hands and plenty of Tory MPs have private healthcare interests including Hunt.
    Perhaps its time for all of us to be innovative but of course our ideas must be informed by left wing democratic socialist ideals!

  5. Bazza says:

    Yes a very good piece and good on social care and how we must have more integration with the NHS.
    My branch and CLP passed a very good resolution reaffirming our support for a National Care Service plus for proper funding for local councils.
    Doing a piece for our branch newsletter I was able to draw on research from The Kings Fund who showed that funding for social care has been reduced by £5 billion in the last 6 years and they called for more Government funding and argued that the burden shouldn’t fall on councils.
    Councils are for now able to raise 3% from council tax to help pay for social care but of course with Tories being Tories this means the top ten richest Tory councils will get £40m between them (the better of areas have a richer council tax base) and the top ten poorest Labour councils will get £17m between them!
    Better funding for social care and the NHS was one of Labour’s 3 key demands from the spring budget so we need to get the fact that Labour is fighting for patients and the vulnerable out there!

  6. Bazza says:

    Oh and just an afterthought but a lot of private care homes are businesses and run for profit, and perhaps this too needs addressing (in line with my initial thoughts on thinking smarter on the NHS).
    Solidarity!

  7. Bazza says:

    Oops NHS funded from general taxation, had had hard day Ha! Ha!

  8. Mervyn Hyde says:

    Thank you for that enlightening read, I will in future keep a close eye on the events as they unfold.

    I received a comment from fellow Momentum members relating to a split in Momentum, at that time of course I knew none of this and was perplexed to hear of divisions in the ranks.

    Bazza: a word of warning about the Kings Fund, whilst they can be useful for the odd quote, they are not fully behind public provision of health and take an ambivalent view on the clear Tory project of privatisation.

    Far better to keep abreast of NHS matters by committed NHS supporting academics is through KNOP, Keep our NHS Public. This article warns you about the Kings Fund: Press Release: STPs will NOT work, King’s Fund
    Posted on 21st February 2017 by Keep Our NHS Public — No Comments ↓

    [Tuesday 21 February 2017]
    The King’s Fund report on delivering the government’s plans for the NHS – Delivering Sustainability and Transformation Plans [1] – does not reflect what is really happening to the NHS in England, and more importantly what will happen unless it is stopped, say Keep Our NHS Public.

    https://keepournhspublic.com/category/news-events/

    We the members must remain in control, it is for us to decide policies and who we support, diktat from the top has no place in a democratic institution.

    1. Bazza says:

      Yes but when something even they find can be used to help our case against the Tories and for better care for patients and the vulnerable use it but of course the middle class Kings Fund would fail to realise that the flat rate of funding for councils re council tax ignores class or rather fails to recognise that the Tories are deliberately practising class politics – as an old Leftie Labour MP from years back (Joan Maynard) used to say: “The Tories don’t preach class politics, they are too busy practising them!”

  9. Mervyn Hyde says:

    Something went awry with my comment above, the bottom paragraph should be read above the NHS comment to Bazza.

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