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Support what the NHS represents – people before profits

Andy Burnham, shadow health secretary, set out the Labour Party’s policy on the NHS and social care at a King’s Fund conference, and launched a consultation process. Here is an extract:

Right now, the incentives are working in the wrong direction. For older people, the gravitational pull is towards hospital and care home. For the want of spending a few hundred pounds in the home, we seem to be happy to pick up hospital bills for thousands.

We are paying for failure on a grand scale, allowing people to fail at home and drift into expensive hospital beds and from there into expensive care homes.

The trouble is no-one has the incentive to invest in prevention. Councils face different pressures and priorities than the NHS, with significant cuts in funding and an overriding incentive to keep council tax low.

So care services have been whittled away, in the knowledge that the NHS will always provide a safety net for people who can’t cope. And, of course, this could be said to suit hospitals as they get paid for each person who comes through the door.

In their defence, councils and the NHS may be following the institutional logic of the systems they are in. But it’s financial madness, as well as being bad for people.

Hospital Chief Executives tell me that, on any given day, around 30 to 40 per cent of beds are occupied by older people who, if better provision was available, would not need to be there. If we leave things as they are, our DGHs will be like warehouses of older people – lined up on the wards because we failed to do something better for them.

But it gets worse. Once they are there, they go downhill for lack of whole-person support and end up on a fast-track to care homes – costing them and us even more.

We could get much better results for people, and much more for the £104bn we spend on the NHS and the £15bn on social care, but only if we turn this system on its head. We need incentives in the right place – keeping people at home and out of hospitals.

We must take away the debates between different parts of the public sector, where the NHS won’t invest if councils reap the benefit and vice versa, that are utterly meaningless to the public. So the question I am today putting at the heart of Labour’s policy review is this: is it time for the full integration of health and social care?

One budget, one service co-ordinating all of one person’s needs: physical, mental and social. Whole-Person Care.

A service that starts with what people want – to stay comfortable at home – and is built around them. When you start to think of a one-budget, one-service world, all kinds of new possibilities open up. If the NHS was commissioned to provide Whole-Person Care in all settings – physical, mental, social from home to hospital – a decisive shift can be made towards prevention.

A year-of-care approach to funding, for instance, would finally put the financial incentives where they need to be. NHS hospitals would be paid more for keeping people comfortable at home rather than admitting them. That would be true human progress in the century of the ageing society.

Commissioning acute trusts in this way could change the terms of the debate about hospitals at a stroke. Rather than feeling under constant siege, it could create positive conditions for the District General Hospital to evolve over time into a fundamentally different entity: an integrated care provider from home to hospital.

In Torbay, where the NHS and Council have already gone some way down this path, around 200 beds have been taken out from the local hospital without any great argument as families have other things they truly value.

Unlike other parts of England, they have one point of contact for the co-ordination of health and care needs. Occupational Therapists visit homes the same day or the day after they are requested; urgent aids and adaptations supplied in minutes not days. If an older person has to go into hospital, a care worker provides support on the ward and ensures the right package of care is in place to help get them back home as soon as possible.

Imagine what a step forward it would be if we could introduce these three things across England. It is a clear illustration of what becomes possible in a one-service, one-budget world with prevention at its heart.

If local hospitals are to grow into integrated providers of Whole-Person Care, then it will make sense to continue to separate general care from specialist care, and continue to centralise the latter.

So hospitals will need to change and we shouldn’t fear that. But, with the change I propose, we can also put that whole debate on a much better footing.

If people accept changes to some parts of the local hospital, it becomes more possible to protect the parts that they truly value – specifically local general acute and emergency provision. The model I am proposing could create a firmer financial base under acute hospitals trusts where they can sustain a back-stop, local A&E service as part of a more streamlined, re-modelled, efficient local healthcare system.

So A&Es need not close for purely or predominantly financial reasons, although a compelling clinical case for change must always be heard and we would never make the mistake of a blanket moratorium.

I am clear that we will never make the most of our £120 billion health and care budget unless hospitals have positive reasons to grow into the community, and we break down the divide between primary and secondary care. It could see GPs working differently, as we can see in Torbay, leading teams of others professionals – physios, Occupational Therapists, district nurses – managing the care of the at-risk older population.

Nerves about hospital take-over start to disappear in a one-budget world where the financial incentives work in the opposite direction. NHS hospitals need the security to embrace change and that change will happen more quickly in an NHS Preferred Provider world rather than an Any Qualified Provider world, where every change is an open tender.

The public are uncomfortable with mixing medicine with the money motive. They support what the NHS represents – people before profits – as memorably celebrated by Danny Boyle at the opening ceremony of the Olympic Games.

Over time, allowing the advance of a market with no limits will undermine the core, emergency, public provision that people hold dear. So I challenge those who say that the continued advance of competition and the market into the NHS is the answer to the challenges of this century.

The evidence simply doesn’t support it – financially or on quality grounds.

If we look around the world, market-based health systems cost more per person not less than the NHS. The planned nature of our system, under attack from the current Government’s reforms, is its most precious strength in facing a century when demand will ratchet up.

Rather than allowing the NHS model to be gradually eroded, we should be protecting it and extending it as the most efficient way of meeting this century’s pressures. The AQP approach will not deliver what people want either.

Families are demanding integration. Markets deliver fragmentation. The logical conclusion of the open-tender approach is to bring an ever-increasing number of providers on to the pitch, dealing with ever smaller elements of a person’s care, without an overall co-ordinating force.

If we look to the US, the best providers are working on that highly integrated basis, co-ordinating physical, mental and social care from home to hospital. We have got to take the best of that approach and universalise it here. But there are dangers of monopolistic or unresponsive providers.

Even if the NHS is co-ordinating all care, it is essential that people are able to choose other providers. And within a managed system there must always be a role for the private and voluntary sectors and the innovation they bring.

But let me say something that the last Labour Government didn’t make clear: choice is not the same thing as competition. The system I am describing will only work if it is based around what people and families want, giving them full control.

To make that a reality, we want to empower patients to have more control over their care, such as dialysis treatment in the home or the choice to die at home or in a hospice. We will work towards extending patients’ rights to treatment in the NHS Constitution.

This would mean the system would have to change to provide what people want, rather than vice versa. An NHS providing all care – physical, mental and social – would be held to account by powerful patient rights.

But, as part of our consultation, we will be asking whether it follows that local government could take a prominent role working in partnership with CCGs on commissioning with a single budget. This change would allow a much more ambitious approach to commissioning than we have previously managed.

At the moment, we are commissioning health services. This was the case with PCTs and will remain so with CCGs. The challenges of the 21st century are such that we need to make a shift to commissioning for good population health, making the link with housing, planning, employment, leisure and education.

This approach to commissioning, particularly in the early years, begins to make a reality of the Marmot vision, where all the determinants of health are in play. Improving PH will not be a fringe pursuit for councils but central to everything that they do.

But it also solves a problem that is becoming increasingly urgent. Councils are warning that, within a decade, they will be overwhelmed by the costs of care if nothing changes. They point to a chart – affectionately known as the ‘graph of doom’ – which shows there will be little money for libraries, parks and leisure centres by 2020.

One of the great strengths of the one-budget, Whole-Person approach would be to break this downward spiral. It would give local government a positive future and local communities a real say.

The challenge becomes not how to patch two conflicting worlds together but how to make the most of a single budget. To address fears that health money will be siphoned off into other, unrelated areas, reassurance is provided by a much more clearly defined national entitlement, based around a strengthened NICE, able to take a broader view of all local public spending when making its recommendations.

It won’t be the job of people at local level to decide what should be provided. That will be set out in a new entitlement. But it will be their job to decide how it should be provided. That would provide clarity about the respective roles of national and local government, too often a source of confusion and tension. But I want to be clear: nothing I have said today requires a top-down structural re-organisation.

In the same way that Andrew Lansley should have refocused PCTs and put doctors in charge, I will simply re-focus the organisations I inherit to deliver this vision of Whole-Person Care.

Health and Well-Being Boards could come to the fore, with CCGs supporting them with technical advice. While we retain the organisations, we will repeal the Health and Social Care Act 2012 and the rules of the market. It is a confused, sub-optimal piece of legislation not worthy of the NHS and which fails to give the clarity respective bodies need about their role.

This approach creates the conditions for the evolutionary change towards the Whole-Person vision rather than structural upheaval. At a stroke, those two crucial local institutions – council and hospital – have an alignment of interests and a clear future role to grow into.

But the same is true for social care. At present, it is trapped in a failing financial model.

The great attraction of the Whole-Person approach, with the NHS taking responsibility for coordination, is that it will be in a position to raise the standards and horizons of social care, lifting it out of today’s cut-price, minimum wage business.

Social care careers would be more valued and young people able to progress as part of an integrated Whole-Person workforce. Of course, the change we aspire to, particularly in social care, won’t come by simply changing structures. It will need a change of culture including leadership, training, working in teams, better information and seeing patients and families as partners in achieving better health and care.  So Whole-Person Care is the proposal at the heart of Labour’s health and care policy review which is formally launched today.

It will be led by Liz Kendall, and will run alongside Diane Abbott’s separate Public Health Policy Review. Over the next six months, we will be holding events in all parts of England seeking views on two central questions.

First, do you see merit in this vision of Whole-Person Care and support the proposals for the full integration of health and social care?

Second, if you do, how far down this path of integration do you think we should go? The fact is that, even if we move to a fully integrated model, and shift resources from hospital to home, it won’t be enough to pay for all of one person’s care needs. We need to be very clear about that.

So this opens up the question of the funding of social care.

It is the case that, with the shift of resources out of hospital, more preventative social care could be provided in the home and, in all likelihood, better standards of social care offered, as we have seen in Torbay. For instance, we have already proposed that this should include people on the end-of-life register. It would also include provision for those with the highest needs and at risk from going into hospital.

But rather than leave this unspecified, people need to know exactly where they stand. Currently, council care provision is the ultimate lottery.

In a single system, it would be right to set for the first time a clear entitlement to what social care could be provided and on what terms, as part of a national entitlement to health and care. That would help people understand what is not covered – which is very unclear to people at present.

But the question arises: what is the fairest way of helping people cover the rest? At present, beyond the £23,000 floor, care charges are unlimited. These are ‘dementia taxes’: the more vulnerable you are, the more you pay. As cruel as pre-NHS or US healthcare.

No other part of our welfare state works in this way and, in the century of the ageing society, failure to resolve how we pay for care could undermine the NHS, the contributory principle and incentives to save. Some people might ask why they should save for retirement, when the chances of it all being washed away increase every year?

In this century, we can’t carry on letting people go into old age with everything – home, savings, pension – on the roulette table.

So there is a political consensus that the status quo is the worst of all possible worlds and it needs to change. We agree about the need to find a fairer way of paying for social care, but not on what that system should be.

The Government have begun to set out their version of Andrew Dilnot’s proposals. A cap, not of £35,000 but over the £50,000 Dilnot recommended, and possibly up to £75,000. This is better than the status quo.

But we all know that setting a cap of up to £150,000 for a couple is not a fair solution. Offering some protection to the better off, but doing little to help a couple in an average semi in the Midlands or the North. But it also fails a sustainability test.

By failing to address the shortfall in council budgets, it leaves people exposed to ever-increasing care charges and more likely to pay up to the level of the cap.

This won’t feel like progress to many. So, as part of Labour’s policy consultation, we will ask for views on other ways of paying for social care.

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