BMA Regional Council,
Thursday, 10th April
The creation of the NHS is Labour’s proudest achievement. More than anything else, it’s what binds us together as a nation.
Our National Health Service is facing the greatest challenges it has known since its inception. The principle of a national health service, free at the point of use, has huge popular support amongst the general public, and it is a sentiment shared by those in this room.
This support will be vital for the NHS to answer the questions that the 21st century is posing.
We are facing a huge sustainability challenge in an era where there’s less money around and these financial challenges will be exacerbated by an ageing society.
There are now 3 million people over 80 and this will nearly double by 2030.
There are increasing numbers with complex needs, mental health problems, or long-term conditions. The number with a long-term condition, such as diabetes and asthma, will rise from 15 million today to 18 million by 2025.
The NHS is on a knife edge. The previous Chief Executive of NHS England, Sir David Nicholson, recently warned that the service faced “oblivion” and that it could not survive if it had to remain in the straitjacket of austerity and keep on the same path it’s on for another parliament.
When the great post-war Labour government created the NHS, the health challenges of the time were very different to the challenges we face today.
Then the priority of the NHS was fighting infectious diseases such as tuberculosis and diphtheria, now 70% of all health and care spending is on treating long term conditions like cancer, heart disease or dementia, while large numbers of patients have multiple needs.
If we are to meet the challenges of providing excellent healthcare and ensuring that people live in dignity into old age without the entire system becoming financially unsustainable, then changes will have to be made.
In their current format, the structures and care pathways that are responsible for our health and wellbeing are unsustainable.
At the moment, we have 3 or 4 fragmented systems to deal with different aspects of health & social care: physical health in acute hospitals; mental health often in separate services on the fringes of the NHS; and social care in council-run services and primary and community services.
People are being passed from pillar to post by different professionals and different points of contact.
People are in hospitals or A&E with mental health problems, but in a system that is only treating their physical ailments.
A quarter of all patients admitted to hospital with a physical illness also have a mental health condition that, in most cases, is not treated while the patient is in hospital.
And people with mental health problems are having their physical health neglected. Those with serious mental health problems die on average 15 years earlier than everyone else.
It is a system that’s working for Whitehall, but not for the people. It’s wasting billions and we end up paying for failure, playing into the hands of the privateers.
People with physical illnesses are struggling with undiagnosed mental health problems. Untreated mental illness is costing the NHS around £10 billion each year.
Care services have been cut in the knowledge the NHS will pick up the pieces – even though it is far more expensive to treat someone in hospital, and it is ultimately damaging both the NHS to care services, and the individual.
People can’t be discharged from hospital because help is not there at home and it’s costing the NHS £4 million a week.
And we are paying for failure: we are paying for people coming through the hospital door, rather than paying to prevent them needing hospital treatment in the first place.
There is a tendency for our hospitals to only see the immediate problem – a broken hip or a stroke – not the whole person behind it.
We are treating a person’s needs through three or four disjointed services. This means not only that we are building up costs at an unsustainable rate, but that patients are falling through the gaps between services and aren’t receiving the care they need.
It’s the way that we have worked for 66 years, and, for the most part, it has served us well.
But in the 21st century when we are faced with increased funding pressures and changing demographics the old model is no longer tenable.
If we want to deliver what people deserve we cannot continue to pass patients around from service to service.
One person, three or four services is not the way forward.
What is needed is a holistic approach to each patient – a single service that cares for a person as a whole.
But this Government is delivering the reverse. Our services are becoming more fragmented, not less, and it is competition, not cooperation that is the driving force behind Tory-led health reforms.
Far from helping integrate services, the Tories’ marketisation is fragmenting the NHS. It’s hard to integrate care when many different providers are all competing for different parts of a patient’s care ‘pathway’.
The Government’s decision to enforce competition law within the NHS will have a chilling effect on the behaviour of commissioners and providers who want to work together– the opposite of the cultural change we need to drive integration.
Last year, for the first time ever, the Competition Commission intervened in the NHS to block collaboration between two hospitals in Dorset and Poole looking to improve services.
Competition lawyers, not GPs are becoming the decision makers in our NHS
Our NHS is becoming bogged down in a morass of competition law.
Since April, CCGs have spent £5 million on external advice as services are forced out to tender.
This competition regime is a barrier to the service changes that the NHS needs survive in the 21st century.
It is sheer madness to say to hospitals that they can’t collaborate or work with GPs and social care to improve care for older people because it’s “anti-competitive”.
If we are to relieve the intense pressure on our services, and rise to the financial challenge, it is precisely this kind of collaboration that is needed, and the marketisation of the NHS must be reversed.
NHS professionals like GPs, doctors and nurses need to play a greater role in coordinating the provision of social care services, and joining them up with other health services.
But despite the rhetoric of Government ministers, the exact opposite is being delivered.
Far from delivering a de-centralised service that puts power in the hands of clinicians, which was the promise of this Government’s NHS reforms, Clause 119, or, as it’s aptly referred to in some circles, the “hospital closure clause”, has been pushed through parliament.
Jeremy Hunt has wrestled power away from GPs and local communities to further re-configure the NHS for non-clinical reasons.
The Trust Special Administrator regime has been distorted. It was never intended as a backdoor way to make unpopular re-configurations, but that is what it has become.
Clause 119 was designed to allow the Secretary of State to do what he failed to do in Lewisham—to close down thriving and financially sustainable hospitals without full and proper consultation.
Sometimes there is a strong argument to close and reconfigure services in a local health economy. In such cases there needs to be a sustained effort to persuade people about the benefits of a reconfiguration, and the arguments need to be clinically led.
It should not be done at the whim of a Secretary of State on the basis of a financial driver. Genuine public engagement is required, not unaccountable decisions decreed from Richmond House by Whitehall bureaucrats.
The Secretary of State’s increased power and Monitor’s expanding role directly contradict earlier Government promises that local commissioners would no longer be subject to central diktat, and represent a reversal of the vision of a decentralised health service that was presented during the passage of the Health and Social Care Act 2012.
Again, what is needed is more joined-up commissioning of health and care services at local level, with NHS and local-authority commissioners working in partnership.
But what we’ve seen is the worst year in A&Es in a decade. It is the consequence of a false economy.
We have seen savage cuts to local Government. Under this Government, almost £2 billion has been taken out of budgets for adult social care. Compared to a decade ago, half a million fewer older people are getting support to help them cope.
A quarter of Walk-In Centres have closed and NHS Direct has been dismantled. Labour’s 48 hour appointment guarantee with your GP has been scrapped.
A recent Care Quality Commission report found avoidable emergency admissions for pensioners topping half a million for the first time – and rising faster than the increase in the ageing population.
Terrible for older people, putting huge pressure on A&Es and costing around a billion pounds a year.
But other vulnerable people are suffering too. The Government is cutting mental health more deeply than the rest of the NHS.
Some mental health trusts are now reporting bed occupancy levels of over 100%. It’s no wonder we’ve heard growing evidence of highly vulnerable people being held in police cells or ending up in A&E because no crisis beds are available.
These are the types of practices that will make our health and care services unsustainable.
If we want to ensure better, more efficient care, especially for millions of older people and those with long-term care conditions who have multiple needs, we need to bring together services and shape them around the individual.
Labour’s whole person care is about putting the emphasis on preventing illness in the first place and preventing costly and unnecessary hospital visits.
Not paying for failure, but preventing people becoming ill and keeping them out of hospital. Not rewarding one part of the system for building up costs elsewhere.
People are often troubled by attempting to navigate themselves through the fragmented systems that take care of their health and wellbeing, so we want to focus on integrated, multi-disciplinary care teams who can work around the individual, rather than the individual working around them, to draw up personalised care plans.
And there should be a go-to person, an advocate or a point of contact, to help a person coordinate their care. People living with long term conditions need to be given more help to manage their conditions by themselves, preventing unnecessary trips to the hospital and delivering more independence to patients.
One of the key recommendations of the Oldham Commission was that annualised tariffs should replace the current payment by results tariff, shifting the incentive to prevention rather than just treatment when things have gone wrong.
What is needed is more joined-up commissioning of health and care services at local level, with NHS and local-authority commissioners working in partnership. And allowing local health and social care services pool to a single budget
Installing a grab rail in an older person’s home might prevent a fall, we could save people a great amount of distress and we will save the service money. If we want a sustainable service that delivers the best for the patient, then incentives need to change.
What the Oldham Commission has set out is a blueprint for how to deliver the changes needed for the NHS to succeed in the future.
And the answer is close the gaps between services that generate false economies and leave patients behind; to integrate services and have a parity between mental and physical health and social care; to work with people to help them stay empowered and independent into their old age and to shift the emphasis onto prevention.
It is crucial not only for people’s dignity, but to ensure that the NHS is equipped to survive and meet the challenges of the next century.
Nye Bevan said when the NHS was founded that it “will last as long as there are folk left with the faith to fight for it”.
We need to continue this fight to safeguard the NHS for future generations.