It seems we cannot go a month without another report landing to shake our confidence in the NHS and social care system. From the horrors of Mid-Staffordshire to last week's reports that death rates in the NHS may be 45% higher than in the USA, questions are being asked about the care provided in our hospitals. Overcrowded emergency departments and reports of substandard homecare add to the sense of services struggling to cope.
The health and care system is facing a perfect storm of rising demand and costs up against flat budgets. The ageing of our population and lifestyle factors like obesity mean that increasing numbers of people are living for decades with multiple chronic health conditions, such as diabetes or heart disease. Budget cuts in social care and related areas such as housing can result in unmet need, which ultimately feeds through to the NHS, the public service of last resort.
It's not just about the money: the nature of the problem has changed. From acute to chronic disease, the system has yet to catch up. Our over-reliance on hospital care is a legacy from the era in which the NHS was established, when, as the OECD puts it, 'sick people were to be cured in hospitals, then sent on their way again'.
When it comes to chronic conditions - those that cannot be cured but can be managed - the patient quickly becomes the expert, providing the vast majority of care themselves. The aim is to help them to self-manage their condition to achieve the outcomes they want, usually to remain independent at home. High-quality chronic care produces better outcomes and reduces costs by avoiding hospital stays, the most expensive form of care. Delivering it requires services to become more integrated, with GPs and hospitals talking to one another, and health and social care working together.
Since the Wanless report in 2002 there have been multiple calls for a shift of focus away from hospital care towards community and primary care services that can help to prevent illness developing or worsening. These trends are not specific to the UK but are seen in developed nations across the world. The shift towards prevention has been a part of policy rhetoric for many years, but has been hampered by short-termism. Politicians are reluctant to prioritise initiatives that will not show benefits until a time when their opponents may be in office, and local health leaders are hesitant to invest when they do not know if they will be able to maintain their commitment.
A 10-year joint funding settlement for health and social care (or five years, with a forecast of the next five years including modelling of demand) would enable commissioners to invest in integrated services, prevention and the technology needed to underpin this, knowing that they will be able to sustain the funding long enough to release savings. The funding settlement should be accompanied by a commitment not to make top-down structural changes.
A decade of stability would create a long-term investment mindset and allow local leaders to deliver the transformation needed. All the evidence from large-scale change programmes suggests that it takes time and requires strong, stable (usually clinical) leadership. A more integrated, preventative system should be designed and developed locally to respond to specific circumstances, strengths and challenges. Making changes to hospital provision is controversial, but local leaders are more able to build trust with their communities and to design new service models with patients and families, increasing the chance of success.
Providing stability nationally would be the quid pro quo for bold reform locally to make the changes needed to the commissioning and provision of care. Central government would gain the right to ask local areas to develop challenging plans to redesign services, and would need to incentivise change and make sure it happened. Transparency and comparison of performance against local plans, strategies for support and intervention for struggling areas, and mechanisms for patients to achieve change both in their own care and in local services more widely, would all need to be part of a progressive reform agenda.
There is much to be proud of in our NHS, but 80% of health leaders believe it needs fundamental change. In particular, many people living with chronic conditions are being let down by a system that - on the whole - is not responsive to their needs, meaning that they end up in hospital because of a failure to provide basic preventative care earlier on. Getting things right for patients with chronic conditions will benefit all patients. More importantly, creating integrated, preventative services that support people to manage their own health will ensure a health and care system fit for the future.
This is an edited extract from the full-length article that appears in issue 20(2) of Juncture, IPPR's quarterly journal for rethinking the centre-left.
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