November 4, 2012
by Tony Beddow
Meeting the health needs of its population is a major challenge for all governments. In most advanced countries, spending on health care provision consumes about 10% of GDP and this percentage is slowly rising. Where Government takes an active role in delivering health care, costs may soon approach 25% of all public spending. However funded, the provision of health services utilises a significant proportion of the available workforce, a high percentage of which is well educated and highly trained.
Individual demands on the health service are heavy at the beginning and end of our lives. Further, ill health adversely affects our ability to work and earn. Thus when we need health care most our ability to pay for it is diminished. Therefore good health care systems have to rely for funding on inter-generational long term insurance arrangements that seek to “pool” the risk. This gives rise to three key questions:
who is best placed to oversee life-time insurance arrangements
what relationship should the insurer have to the main providers of health care services
what place if any should “co-payments” for health care by families or individuals have alongside “insured” risks.
Although health services are constantly changing to meet new and emerging challenges, the NHS must cure when necessary but care always. Labour’s principles remain constant.
Health care is best funded from national taxation with Government acting as the “insurer” through social solidarity, offering health needs -related cover from cradle to grave – where “need” is determined through a political process that draws upon evidence and professional advice to complement public opinion; co-payments should be minimal – used only when they do not impede access to treatment for significant and/or chronic conditions.
The health of the nation is best safeguarded through firstly tackling causes of ill-health and one seamless care system that prevents what can be prevented, diagnoses quickly what has not been prevented, treats in a timely and evidenced-based way what has been diagnosed, and delivers effective and compassionate care, whether for acute or chronic problems and respects the dignity and wishes of each patient as a human being. The NHS needs to work seamlessly with social care and other local authority services which contribute very significantly to the health of the population. Excellent care needs to give the patient a sense of control over their health and their treatment, including palliative care.
Efficient and skilled primary care services are the foundation of an effective heath care system; to retain world class and integrated primary care services the NHS will have clear “franchise” arrangements with the four independent contractors (GP’s dentists, pharmacists and opticians) or will directly provide primary care services where necessary. Aspiring GPs and dentists should have a choice of joining locally sensitive independent partnerships, or NHS-run primary care services. Here “franchise” describes a key component of the care system that has to conform to the standards and systems of the NHS but has been, or should be, locally and independently managed. This notion could also apply to air ambulance services and other charitable provision such as hospices where appropriate.
That to ensure quality and broadly equitable service provision right across the country, Government must directly own and manage hospital (secondary and tertiary) components of the system; the NHS locally may choose to use competent private sector clinical skills in clearly defined circumstances, for example where these offer novel services otherwise unavailable, to remedy persisting inadequate standards, or to meet peak service pressures when NHS capacity is not immediately available. There should be a form of local accountability for the services provided and the outcomes achieved to the community of people using those services and their families.
The NHS must have clear and reliable contract or grant aid relationships with other important and longstanding elements of the care process when “franchising” is not appropriate – for example hospices, air ambulance services, and substance misuse services – where the NHS decides that a non statutory operator offers distinct service advantages
The NHS must not only meet today’s health needs; it must understand and prepare for the demands of future generations using the best available epidemiological and other forecasting techniques and here the public health function has a planning vital role that complements its operational role in combating communicable diseases and environmental threats to public health. Social care and other local authority provision should be included in these plans.
The NHS must work closely with bodies that help educate and train the future NHS workforce to meet the needs of patients efficiently and effectively. Traditional professional boundaries and curriculum content should be regularly reviewed to make sure that it is the future needs of patients that is the sole driver of curriculum and Continuous Professional Development. Lay representation should have a role to contribute to the existing professional inputs.
The NHS does not operate in isolation; it must work with, and influence, a range of key partners, in the private, public and voluntary sectors. These include a range of bodies that help shape the environment which affects the level and nature of health. These must include social care and other local authority services. At the national policy level, the NHS must inform relevant policy in other departments whose actions have health consequences.
The health service must ensure collective and individual accountability throughout. NHS services must be responsive, working closely with local authorities, to needs and wants of the populations they serve, as part of a long term dialogue. All care must be delivered with as much participation in shared decision-making as the patient wishes at the time. In particular, all planning functions must be democratically accountable.
The NHS must maximise environmental sustainability.
The determinants of healthy populations and individuals
Although the NHS is a vital service, it cannot ensure healthy populations or individuals. Good housing, safe environments, good parenting, genetic inheritance, social capital, “herd immunity” from preventable diseases though immunisation programmes, and personal or family income levels, are among the many determinants of good health. There is a well-documented body of evidence on the problems – and particularly in recent years that of Michael Marmot – which also points to the solutions which will tackle the main problems. This evidence should be built on with the establishment of an Office of Health Equalities within government, but independently constituted. It should assess cost effective measures to overcome health inequalities; be funded to monitor progress on overcoming those inequalities which undermine health; it should report on the costs of ill-health; and report annually to Parliament. Its main remit should lie outside the NHS.
Local authorities have always been key players in the wider determinants of health both in terms of the services that they provide but also the degree to which they and others are active in facilitating community engagement. There is evidence that in areas where there are stronger social networks and higher levels of trust, health and well-being is enhanced. The lifestyle choices that individuals make – what is eaten, drunk and smoked, and the activities pursued that help maintain good mental and physical health – are also significant. There is strong evidence too that societies where income differentials are not excessive are healthier than those where income differentials are high.
Maintaining high quality services for all
The delivery of good care is an intensely human process – whether a short one-to one interaction or a long term relationship between service users and a variety of health professionals.
Labour believes market-style behaviours and incentives have a limited application in delivering high levels of consistent quality care. Of much more importance are:
Skilled and motivated clinical, support and managerial staff who share the aims and ideals of the NHS and who take responsibility for their own continuous learning and who are themselves well-cared for as staff.
The use of regularly updated evidence – based diagnostic, treatment, and rehabilitative care standards and pathways that accommodate patients care choices wherever sensible
The engagement of patients and family / carers in the care process as co-producers of health outcomes and the provision of good information to patients to enable them to be actively engaged. Values of known importance to patients such as dignity and respect should be fully demonstrated in every service provided for each patient.
Widely available and meaningful information about the performance of and outcomes from health care services
A supportive but challenging work place culture that operates to a public service ethos that cherishes the skills of its workforce, recognises the pressures under which it sometimes labours, but is very intolerant of poor outcomes and yet is institutionally willing to identify faults rapidly and uses them to improve future decisions and outcomes
Professional peer review (and inter-professional peer review) to maintain high care standards across the health professions.
Multi-disciplinary work that, for instance, integrates social and primary care.
Labour believes that further major, rushed re-organisations of the NHS work against the interests of patients. Repeated major structural reorganisations in the NHS have often not been effective in improving care for patients and are very costly. Better to hold fast to the principles above and in parallel, coolly analyse the problems current in healthcare delivery in order that the most effective means can be identified and put in place to address those problems. For example, in addition to the key problems of escalating costs and inequity in health care, we identify the following current problems:
Unacceptably wide variation in the quality of primary care, especially in inner city areas: there is evidence that some of the variation in cancer outcomes in the UK compared with other countries has arisen from late diagnosis and referral
Unacceptably wide variations in the standards of nursing care especially in non-specialist areas and a lack of respect and dignity in the manner in which some people, especially those with long term conditions, much older people or those with learning difficulties are treated, causing immense distress
A lack of genuine engagement between health care professionals and patients with decisions about patients’ health and heath care
It is essential that the NHS should retain the confidence of the taxpayer and its users. Transparent, accessible and independently validated comparative performance data should be used to indicate the effectiveness of the NHS. This will describe its effectiveness at two levels, national and local.
Nationally, UK comparative performance in terms of health inputs, care processes and patient outcomes (both patient and clinician reported) will be used to ensure the NHS matches the performance of the best European systems. The average length of life both attained and forecast at national and sub national levels, the number of life years lost, and the quality of life in key respects (especially for the last decade of life) will inform these measures. The independence of the public health function is important; the Chief Medical Officer will be required to submit an annual report directly to Parliament charting progress in these areas.
Locally NHS services – both directly provided and franchised – will be compared and reported on a number of key indicators. These will include:
Timeliness of access for diagnostic, elective, and emergency care at primary and secondary locations
Clinical quality of care in terms of outcomes and adherence to evidence based treatment protocols
Patient experience of the whole care process and the extent of “co-production”
Utilisation of human, financial, estate and consumable resources
The efficacy of local peer review mechanisms
Local authorities have a key role to play in holding local health care services to account for their performance.