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NPF Report reviews: Health & Care

There is nothing like a snap General Election to shake health and care priorities out a thicket of possible options and fuzzy thinking. And like the rest of the document, the health and care proposals in the Labour Manifesto struck a chord with the wider public and with health and social care staff.

The headline messages from the Manifesto were an increase in NHS and Care spending of £38 billion over the lifetime of the next parliament. This makes sense as it is clear that NHS performance has deteriorated as public investment has declined. To get the best value from these increases Labour promised to invest in staff, end the commercialisation of care and to promote greater cohesion within the health service itself and with social care. Mental health funding would have a new priority with a ring-fenced budget and a greater emphasis on the needs of younger people.

The importance of public health from its narrowest personal prevention programmes to the wider social determinants of health and well-being was recognised throughout the Manifesto from commitments to renew and humanise the social welfare system to tackling low pay, social isolation, the housing crisis and the environmental agenda.

The Health and Care Policy Commission report on National Policy Forum work is mainly an account of what has been going on rather than a considered statement of policy for a future Labour Government. It is a report on “work in progress” which was interrupted by the General Election.

A key outcome of the General Election has been to redefine what is the “politics of the possible”. The Health and Care Commission (HCC) will have to catch up with this as it provides the impetus to consider a wider range of public service options and solutions to the key challenges we face.

Much of what has passed as health and care policy over the last decade has been set in the context of a declining role for public provision and a growing role for the “personalisation and commercialisation” of care. But the popular support that the Labour Manifesto attracted shows that this approach is no longer the only game in town.

An initial challenge for the Health and Care Commission and the Labour Party generally is lay bare the bankrupt nature of Tory policy. Austerity has meant less investment in public services. And Tory (and Coalition) policy has followed from this. Everything has been geared to extract more and more efficiency out of relatively smaller budget. But in the face of a decline in health and social care performance it is clear that none of the preferred solutions were actually working.

The traditional commercialised internal market policy has created fragmentation and incoherence. Eventually even the Tories recognised this and under the auspices of Jeremy Hunt and NHS England Chief Executive Simon Stevens a shift toward Suitability and Transformation Partnerships/Plans (STPs) began to take place.  The messages sounded good – “less wasteful competition and fragmentation” and more working together. But STPs were doomed for the start because their purpose was to deliver more from less. The public and health care workers were rightly suspicious as they believed that STP decisions were more about creating a service to work with an inadequate budget than one responding to identified need.

As the STPs have stuttered and struggled new care models under the banner of accountable care organisations (ACOs) have been promoted.  The Kings Fund health think tank says “The language of accountable care comes from the United States, where ACOs have taken shape in the wake of Obamacare as an attempt to improve care and reduce growing health care costs.“ ACOs are discrete service organisations which can package a range of shapes and types covering community to specialist care. There  is no commitment to a public service delivery model so each ACO is a potential commodity in the health care market place. The ACO model therefore  NHS and social care open to even greater penetration by corporate and commercial bodies. Professor Stephen Hawking was correct to speak of his worries that these developments can become a black hole for the NHS.

The Health and Care Commission must not allow itself to get dragged into a debate about the fine tuning of these dubious models of care delivery. The Labour Manifesto said it would halt and review the NHS Sustainability and Transformation Plans and this must the point of departure.

At the heart of the problems of NHS delivery in England is the continuation of an internal market of varying sorts. The HCC needs to take this on board and start developing a pathway based on a public service model. This will not necessarily involve re-inventing the wheel as the NHS in Wales and Scotland have both gone down this road many years ago. Things may be be more complex in England as neither Wales or Scotland allowed themselves to be as entangled with the commercial sector as NHS England but both these countries continue to show that markets and tendering are not intrinsic to the  delivery of modern public service health care.

Social care became one of the hot issues in the General Election when the Conservative proposals for what became known as “the dementia tax” showed how adrift they were from their own core support and reality. The Labour Manifesto recognised the importance of the issue by pledging an additional £3 billion to ensure a maximum limit on lifetime care costs as well as raising the threshold at which people become eligible for paying for social care. In the devolved administrations there are important variation in policy with Scotland providing free personal social care and in Wales there is a cap on the maximum a person will play for domiciliary care per week.

The interface between health and social care is a difficult one as health care is comprehensive and free at the point of use whereas social care requires a needs assessment and a means test.  While waiting times are the main way of “rationing” NHS care, changing eligibility thresholds can exclude people from publicly funded social care. The HCC reports that there are 1.2 million people living with unmet social care needs which reflect the anomalies in the present system.

Brexit could also have devastating effects on social care. Very many care workers are amongst the lowest paid in the UK. This means that the sector faces continuing, major recruitment problems and is very dependent on workers from the EU. A hard Brexit could result in major staff shortage as the sector unable to afford the pay levels which are required to compete competitively in the labour market without further major investment.

The Labour Manifesto indicated that a Labour Government would look at the way social care is funded. It is a matter of concern that the Commission has not to date taken this as one of its major tasks.

For most of the last three decades health and social care has been a very enjoyable playground for neo-liberal and social market policy makers. There was an endless production line of ingenious new schemes and wheezes on how the services should be delivered. The one idea that they always seemed to miss was an adequately funded service, based on need, free at the time at the time of use and publicly provided.  June’s General Election showed that this is an idea whose time has returned. The Health and Care Commission must be fully awake to this and set about providing the Labour Party with the strategies and policies to respond to this demand.

It would not be unfair to say that  the  Labour General Election Manifesto  rather than this report  has  advanced Labour’s health and care policy the most. This raises questions about the way the Health and Care Commission works. It must be able to step beyond the “group think” that has dominated health and care policy for recent decades and embrace the real concerns of service users and health care staff. The issuing of this bland narrative report is no substitute for such democratic involvement.

7 Comments

  1. JohnP says:

    Good article, Brian. Once again though, the actual value of the endless, but astonishingly unproductive NPF process , calls into question whether it is worth the bother – when Andrew Fisher and a few helpers can knock up a Manifesto in a couple of weeks which is hugely popular, and advances Labour’s policy offer, in Health, and every other topic area, to a degree the NPF can only dream of !

    But then the entire point of the Labour Right dominated NPF merrygoround of vacuous reports is probably precisely to NOT develop any policy , leaving the neoliberal existing policy bundle sagely in place by default.

    1. David Pavett says:

      This excellent report, like the others previously published, does indeed call into question the workings of the NPF. I think, though, that there is a need to be careful with where we take that thought.

      There are those on the left who conclude that the NPF is useless and should be dismantled to leave policies to be determined by debates at Annual Conference. I think that this is a very bad idea since the requirements of policy development go far beyond what can be achieved in a few days at an annual conference. The careful production and consideration of documents dealing with alternative approaches to complex issues cannot possibly be dealt with like that.

      It may be responded that the NPF shows no signs of considering such well prepared documents laying out the cases for alternative approaches. And indeed all the signs are that it does no such thing. The solution is therefore that the NPF and its Policy Commissions must be reformed to run in a very different way so that they do those things. That would require an open method of working with the programme of meetings, agendas, discussion papers and minutes all being made available to the members. Each Policy Commission should have a website on which members are kept posted of latest developments. In other words we should demand proper programmes of work, openness and far better information to CLPs and branches about the work as it progresses.

      It is true that the small group who wrote the Manifesto did a good job in a very short space of time and left the NPF far behind. But that is an argument for having a sense of urgency in developing policy and of being committed to radical solutions. It is not an argument that Party policy should be decided by small groups putting things together in a hurry.

      At present the NPF seems to have no concept of openness. That has to change and it has to change in a big way. It is time for a shake up of the policy process.

      1. Spot on David Pavett. I have written and read other similar contributions on the LP online policy forum… But no feed back on what is going on. LP policy makers need to listen to front line staff at all levels… not just senior commisioners, policy wonks, doctors and nurses! Support and care workers have highly valuable experience of what we need from a Labour policy and what will work.

  2. C MacMackin says:

    Thanks for the informative report. One of the great triumphs of the NHS was to provide care that was not only comprehensive, but integrated. Other country’s health systems don’t always do as well with that task. Unfortunately, neoliberal reforms are now putting that at risk. I also appreciated that this piece illuminates the disconnect between the NHS and the social care system. It seems to me that it’s about time we do for social care what Bevan did for the healthcare, creating an integrated, national, publicly owned system which is free at the point of use.

  3. Peter Rowlands says:

    Thanks for a very good report, in particular highlighting the threat from so called ACOs, and the all important issue of social care, as Chris M has also stressed.. We are committed to an integrated service here, and after the Tories’ unpopular and now withdrawn proposals prior to the election now would have been the time for some radical policy from us. It’s a pity that that has not been attempted.

  4. Bazza says:

    Good piece and it seems the rich and powerful and their Tory puppets use working people all their lives then perhaps (in their eyes) they are surpluses to requirements?
    But as suggested here we should have policies which repect and value older citizens and they have much life experience to still share with us all and we should also try to utilise this too.
    To help fund it we need to get much of the wealth back from the rich and corporations including closing tax loopholes (I recently read that there are well over 2,000 different tax reliefs for the well-off) as well as closing tax havens.
    And we should make a big song and dance about telling the rich that they are helping to pay for dignity in care for older people!
    We should end the rich and corporate gravy train with the Tories stuffing the mouths of the rich with gold whilst some of those who have given to society all their lives get a second class service.
    We also need to reward the workers in social care and Labour’s idea of migrant workers needing job offers should deal with Brexit concerns.
    Dignity, good quality (was reading how Virtual Reality was being utilised for example to aid some older people with dementia), well resourced, public service.
    Social Care is perhaps often seen as a Cinderella Service but thankfully as we have a growing older population we need to put it higher up on the political agenda.
    Like pensions perhaps growing old is something many tend not think about but if we sort it now we all benefit!

  5. Pablo says:

    Wallasey CLP has a crowdfunding page open to help fund our delegates to go to Conference. If anyone can help, it would be much appreciated.

    https://www.crowdfunder.co.uk/help-send-wallasey-delegates-to-conference

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