Andy Burnham’s “whole person” care

On 1 April the coalition government’s Health and Social Care Act 2012 will formally end the health secretary’s duty to secure or provide comprehensive health services in England and also the government’s responsibility to provide for all our health needs, free of charge. Instead a range of bodies, not directly accountable to parliament, will decide which services will be freely available and to whom.

From now on, it will be hard to know who is responsible for what and whom to hold to account when things go wrong, because the new act, with its emphasis on multiple systems of competing providers and commercialisation, lends itself to further fragmentation of care domains. Robert Francis’s report on Mid Staffordshire clearly shows the failure that resulted from increasing marketisation, as managers put performance and financial targets before the needs of patients.1

That we are living longer is self evident, but as we live longer many of us are growing to fear old age—a fear heightened by stories of older people being abused or neglected in hospitals and care homes. Many of us also fear the financial costs of old age, as savings are obliterated to pay for expensive care. The 2012 act will not reduce these fears or meet the challenges facing patients with needs that span the physical, psychological, and social domains.

As we live longer, the division between our healthcare and social care needs becomes increasingly blurred, making it nonsensical to have competing systems that are based on separate services, separate funding streams, and separate staff. This was the basis of the shadow health secretary Andy Burnham’s announcement on health and social care, delivered to the health think tank the King’s Fund on 24 January.2 3 The more care needs a patient has, the more important it is for the different parts of the “caring” system to work together to coordinate the care. This also ensures that care is provided on the basis of need and not on the basis of differing entitlement criteria.

No structure in a complex system is ever perfect, and Burnham has promised to work within current structures. However, he would move control over the planning and purchasing of health and social care away from clinical commissioning groups (CCGs) to the health and wellbeing boards, though retaining CCGs as advisory groups. This would result in the full integration of health (physical and mental) and social care into a single organisation with one budget and one service, coordinating all of a person’s needs—physical, mental, and social. The idea is to “tilt the entire system away from hospital towards home” and away from the traditional “patient centred” medical model to a more inclusive “person centred” one.

Burnham’s whole person care promises to abolish the 2012 act and the rules of the market and with it the policy of “any qualified provider” and competition for its own sake. The NHS would become the preferred provider, with third and private sectors providers adding value where needed. Burnham proposes a new system of payment for social care (akin to national social insurance), such that our care would be free at the point of need.

The proposal makes sense, certainly to general practitioners, who are perhaps the only part of the health system that deals with the totality of a patient’s needs—often spending days trying to coordinate care between the three services. It is vital, however, that the new proposals build on the strengths of general practice as the natural medical home of the patient.

The proposed reforms do, of course, have risks, such as that:

• Funding would be siphoned away from health services to meet the ever increasing need for social care (if social care entitlements are going to be increased, they need to be fully funded)

• Yet more structural reorganisation would be needed—together with the morale sapping effect that such reorganisation has on those of us who work within the care system; and, most importantly

• The new integrated care organisations would become hospital facing and hospital led, leading to the demise of general practice as the focus of care for the vast majority of activity.

Other questions are how care could be fully integrated if the duty on the health secretary has been abolished; where responsibility for securing services for a given area’s population would rest; and whether local authorities would in future be permitted to charge for services, and if so which.

The future could be bright, though, with the full integration of health and social care and the right incentives in place to keep people out of hospital. But we must build on the whole person nature of general practice, with its community orientation and generalist skills, if we are truly to create a health service that meets the needs of the future.

As the cliché goes, only time will tell whether Burnham could be more successful than his predecessors, but the room at the King’s Fund was filled with enthusiasm, and an air of hope has returned.