Future proofing the NHS: the new care modelsBMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h1505 (Published 31 March 2015) Cite this as: BMJ 2015;350:h1505
- Nigel Hawkes, freelance journalist, London
We have seen the future, and it is quite confusing. That’s because several versions of the future are jostling for the limelight, each slightly different from the next.
Is the future to be combined health and social care, as exemplified by the Better Care Fund,1 where investing in social care aims to cut admissions and pay for itself? That was the idea before last, so it’s disappeared from the headlines for the moment, but work hasn’t stopped.
Is it to be the Manchester model of semi-devolved budgets run by shared NHS and local government authorities in the big cities, unveiled with much excitement in March?
Or are the new care models in the 29 recently announced “vanguard” sites the shape of the future NHS in England? These come in three different flavours, by the way, just in case anybody isn’t concentrating.
A cynic might say that all this activity is smoke blown in the face of the electorate to distract attention from the actual state of the NHS as the election nears. The timing and content of the Manchester announcement, in particular, was strongly political—the chancellor of the exchequer, George Osborne, not only stealing Labour’s clothes but stealing them from its own washing line. Labour doesn’t like to see a Conservative chancellor strutting his stuff in its own back yard.
The Stevens solutions
There’s more than politics going on, however. Simon Stevens, chief executive of NHS England, really does believe in a pluralist model where different localities can devise their own solutions. It is a complete change from the hierarchies of command and control that have run the NHS in the past. We’d better believe he means what he says, even if we harbour doubts about how well it is going to work.
Of the futures outlined above, the one that is closest to Stevens’s heart is the new care programme, underpinned by a £200m (€270m; $300m) fund and launched in the 29 “vanguard geographies,” that emerged triumphant from a competition designed to find the best ideas from across the NHS in England.2 Nine of the 29 are called integrated primary and acute care systems, which roughly translate as the vertical integration of hospital and primary care, while 14 are multispecialty community providers, which are out of hospital care organisations run by GPs. And a further six are described as enhanced health in care homes, a new category to me. They are NHS only schemes, not involving any budget integration with social care.
The problem, as with all such pilot schemes, is that areas that are already innovative win the prizes for work they may in some cases have already started. More backward areas either don’t enter or don’t win. So the risk is that a series of show villages is created where the crops are plentiful and the peasants smiling but that don’t spread good practice more widely. Whatever else the NHS in England has lacked, it has never been pilot schemes, some of them quite impressive.
The Manchester initiative is actually quite different, though presented by Stevens as part of the same devolutionary path. In this case, health and social care budgets will be combined, and control over £6bn a year of spending will be handed to a new partnership board for a population of three million people.3 For the first time it will put local government in with a hand on the steering wheel, a prospect that divides opinion. Labour ought to approve, because this is also its plan, more or less. A smart response might have been to point this out rather than making the flat footed claim that devolution runs a risk of creating an NHS that is no longer truly national. That has been true ever since a Labour government first devolved power over health budgets to Scotland and Wales. You can’t have localism without variation.
The separation of the NHS from local government was a political necessity at the outset, because winning the consent of doctors depended on guaranteeing their freedom from local politicians. But the policy had perverse consequences. NHS budgets became opaque, with very little appreciation of what it actually cost, in turn allowing lazy thinking to thrive. It’s not difficult to defend “our NHS” if you are writing a cheque for somebody else to honour. Contrarily, keeping democracy out of the NHS did provide protection from the madder moments of local government in the 1980s. It’s an obvious contradiction that the Conservatives are eager to encourage free schools and academies outside local authority control while backing the Manchester initiative so strongly.
It will be interesting to see whether involving the local authorities in Manchester makes controversial service changes any easier. That would be a plus, because in any future service model there will be losers as well as winners. The physical structure of the service, particularly its hospitals, engenders strong local loyalties that often trump changes that would deliver more to patients.
There is not much now between the two main parties, and the greatest service either could do for the NHS would be to keep it that way. There are bound to be hot words in an election campaign, but Labour should not resile from good policy out of pique, nor should it paint itself into a corner over Stevens. The bust up at the House of Commons Health Committee over Labour complaints that a draft report bore too strong a Stevens fingerprint is worrying. The fact that Stevens used to advise Tony Blair doesn’t help. But we can’t afford another reform dying before it has even been tried.
Cite this as: BMJ 2015;350:h1505
Competing interests: See thebmj.com/about-bmj/freelance-contributors/nigel-hawkes.
Provenance and peer review: Commissioned; not externally peer reviewed.
thebmj.com News: Politicians set out their stall at health election debate (BMJ 2015;350:h1601, doi:10.1136/bmj.h1601); Observations: The Better Care Fund: a disaster in waiting? (BMJ 2014;348:g3345, doi:10.1136/bmj.g3345)
For more from The BMJ on the UK general election go to bmj.co/election.