NHS and Social Care - Dispute of Success

Transcription

1 Conservative Conference Fringe: NHS and Social Care how will today's decisions shape tomorrow's services? (Novares Monitoring) 8 October 2012 Sponsors: Health Hotel - Anthony Nolan, Care & Support Alliance, Medical Protection Society, Royal College of Midwives, Tunstall and Barchester Speakers Polly Toynbee, columnist, the Guardian Stephen Dorrell, chair of the Health Select Committee Cathy Newman, presenter, Channel Four News (chair) Panel Dr Stephanie Bown, Director of Policy and Communications, Medical Protection Society (MPS) Prof Cathy Warwick, General Secretary, Royal College of Midwives Simon Gillespie, MS Society (also representing the Care and Support Alliance) Henny Braund, Chief Executive, Anthony Nolan Summary Cathy Newham stated that when the economy has been dealt with, the NHS is the next biggest challenge. Tackling the NHS reforms and addressing reforms ducked by generations are the key tasks. This requires bravery, but Jeremy Hunt is obviously brave, after his recent abortion comments. She asked if he would merge hospitals and let private sector organisations take over failing hospitals. The next election will be about the election, but also about the NHS. Polly Toynbee stated that she is sorry not to be debating with the Secretary of State: she wished that Stephen Dorrell was in fact the Secretary of State. Dorrell has stated that no health system has ever been squeezed to deliver such a high level of savings. She questioned how many GPs will be involved in clinical commissioning groups (CCGs), and there is nothing stopping GPs referring people to their own surgeries. The whole emphasis on competition is worrying - Monitor is driving competition, not integration. There is enormous commercialisation in the NHS, and this is due to increase. She asked if CCGs would be good at drawing up contracts, after problems seen with the Government's drawing up of train contracts. She asked if the Care Quality Commission (CQC) could monitor more organisations, and if there would be fewer whistle-blowers because of the pressures of being in a commercial system. There should be an incentive to treat people in the community. It is deeply alarming not to get integration of social care in the system. Stephen Dorrell stated that it is right that new structures cause disruption. The new structures will look strikingly familiar to the structures created by Alan Milburn and Ken Clarke when they served as health secretaries. Clinical engagement and public health in local authorities are steps in the right direction. The purchaser provider model, and the clinical provider model of the past is recreated under clinical commissioning. The history of this parliament will be people asking what happened in the NHS. People did not know the old structures, so would not know the new.

2 The Nicholson challenge, eliciting savings of between 15 billion and 20 billion, would see savings reinvested. Demand on the health system grows at four per cent per annum. Since the creation of the NHS, three per cent has been met by increased funding, and one per cent through growth in efficiency. The NHS has never offered more than two per cent efficiency growth in a year, and four per cent is being called for. This has not been seen regularly in any system in the world. However, this is not impossible. The way the challenge is met is by looking at hospitals, primary care, housing and social care. If the elderly are looked at, the predominant users of the system, then the service focus on this group would deliver a better and more efficient system. The current system is unaffordable. High quality care Bown stated that the number and cost of claims brought against the NHS is rising - last year this was 9,000, paying out 1.1 billion in compensation. The General Medical Council (GMC) reported a 23 per cent increase in complaints against doctors last year. Doctors now have a one in 64 chance of being investigated by the GMC - the highest ratio in the world. The Royal College of Physicians shows that 50 per cent of middle ranking doctors have little or no job satisfaction, showing low morale in the NHS. The Francis report on Mid Staffordshire is waited upon. There is insufficient focus on the patient; staff need to be empowered and to raise concerns - 60 per cent of doctors in an MPS survey did not have confidence in the mechanism to raise concerns. The primary responsibility on quality lies with hospital boards. Toynbee stated that much faster investigations and apologies could reduce this level of payouts. Many people get angry with the process, and then sue. This should be a high priority. Dorrell stated that an open culture is necessary. Quality cannot be inspected into an organisation. Quality is owned by the professional people, not the board. The culture in the professions needs to encourage and nurture this desire for quality. He stated that he is concerned that Francis will lead to a knee-jerk reaction with more clip boards and inspections, whereas quality should be owned by the professionals. A representative from National Voices asked how patients can be listened to and acted upon. Dorrell stated that medical training states early on that engaging patients is the only way to treat them. This is an important part in changing what a professional means. On capping NHS payouts to the same level as employment tribunal payouts, Toynbee stated that she could see the benefits of this. Suing government for large sums is the wrong approach, and there should be a cap on this. Bown stated that there should be some limits to compensation. Care has been limited to a certain number of hours or compensation restricted in some countries. In 70 per cent of cases the MPS is involved in, the lawyers are receiving more than the victims. On if Mid Staffordshire could happen again, Dorrell stated that only a fool would say it could not, and it is about making it less likely. Culture, management and professional cultural failures led to Mid Staffordshire. There should be early resolution and culture changes to make mistakes less likely. He stated that he wanted doctors to know they are doing the right thing for their patients, and if there are risks the patient should take them.

3 Choice and control Cathy Warwick stated that the Secretary of State's extraordinary outburst on abortion over shadows this issue. There is no evidence that the current time restriction on abortion should be changed; this is extremely worrying. This runs contrary to the coalition's call for choice and control. Choices can give patients control, putting them at the heart of their care. Unless there are limits for choice, this could limit other choices. If a woman should be able to opt for a caesarean section, this could lead to a lack of choice for another woman to have an epidural or a home birth. There is an argument that choice does drive improvement of services through competition, but the King's Fund shows that most people go for their local provider, based on their experience, the experience of friends or the advice of their GP. Improvements should not be driven through competition, but through exacting national standards that are based on integration. Toynbee stated that there would be no choice in the system, as commissioners will decide on services; the 'no decision about me without me' comment is a blind. Choice all round would be restricted. To have choice, there has to be spare capacity. People would choose based on waiting lists. It will be very hard for politicians to know what closures are the right ones, and which the wrong ones. Andy Burnham stated that he would not join every picket line against hospital closures. Dorrell stated that 'no decision about me without me' is from the Picker Institute, and this is something that no one is against. This is just good medical and nursing practice. The National Audit Office (NAO) stated that 30 per cent of hospital admissions are avoidable with community and preventable services. These will only be achieved if more is spent here and less in hospitals. And this is what commissioners would have to do. A representative from Mencap stated that those with severe learning disabilities have choices restricted, and some are sent to residential centres such as Winterbourne View. Mencap called for these facilities to close, to be replaced by local services. Toynbee stated that it would be hard to do anything that would cost more; she suspected that large centres are cheaper than community services, to which she was told that the contrary is true. On choice in mental health and whether people actually wanted choice, Dorrell stated that it is a strange choice to have choice but not on who provides the service. it should not be the case that the decision maker always knows best. If the term 'no decision about me without me' can be depoliticised, then progress can be made. The model of care needs to address needs, and he did not buy the line that care for mentally disabled people was unaffordable. How to pay for social care and health Simon Gillespie stated that there needs to be a focus on people, not just patients. Patients and their carers form part of this. 800,000 older people receive no help with their support needs, and this is growing. There is huge unmet need, and there would be growing demand for services. The question is who pays, for what and when. An ageing population, people with two or three conditions and disabled children reaching adulthood are key issues. Dorrell stated that there are growing requirements on the system. The NHS and social care budgets should be spoken of as one, which would make 150 billion, but social housing should also be added to this. The question is how joined-up, personalised and sensitive care is delivered.

4 There are separate bureaucracies around health, social care and housing, with separate IT systems. These needs to be joined-up. The health select committee has called for a single commissioning budget for people who had suffered a stroke, dementia patients or the elderly. Health and wellbeing boards are the best seed to deliver joined-up services. Toynbee stated that if only reorganisation had started with the patient. 90,000 NHS staff had to reapply for their jobs because of reorganisation, and she hoped this would not be repeated. Perhaps pilots could bring these strands together. The population needs to be identified and organisations need to agree to bring budgets together. She stated that politicians had been cowardly; people should pay for some social care when they get old, but not all. Dorrell stated that Lansley had told the Health Select Committee that Dilnot would be included in social care legislation if there was a political consensus. A representative of Barchester Healthcare stated that personal budgets have not been mentioned, allowing people to commission their own care. Dorrell stated that he is in favour of increased personalised budgets. There are users of the services that have budgets managed for them, and where people manage them themselves. It is important to be careful of the rhetoric around personal budgets. This is not the single solution to the whole problem. Toynbee stated that Conservatives supported this because it is a voucher scheme that people can top up. This then undermines the health service. A representative of the Patients' Association asked if health and social care should be brought together, like in Northern Ireland. Dorrell stated that the only way the Nicholson challenge can be met is by rethinking care, making sure the care system meets today's needs. Changes have to be incremental, but a fundamental redesign is needed. Toynbee stated that she had seen personal budgets work well. This is seen when patients actually help each other to commission. When this is done right, getting patients to take responsibility for their care, then it works well. On the Local Government Association's (LGA) comments that local authorities would just look after bins in the future as they would not have the funds to provide social care, Dorrell stated that this is a challenge. Toynbee stated that there is untouched wealth in housing held by those in their fifties, as many made money from a property boom, especially in London. Those reaching retirement should be told how much of this they should give to support their care. Dorrellstated that of the 60 billion spent on acute hospitals, 30 per cent could be saved as the NAO reported. Innovation in the NHS Henny Braund stated that informing clinical behaviour, not just new drugs or devices, could deliver efficiencies. The lack of intellectual property from such research hampers investment. The culture

5 needs to change so that clinicians think about this, and investment is needed. This might be around prevention or working out of communities. Dorrell stated that innovation is more about care and support, and is about thinking differently to deliver care. This delivers better quality care. A grab rail costs 30, but this can stop someone appearing in a fracture clinic, costing 10,000. This saves costs and improves care. This is as much innovation as the new product coming from the pharmaceutical companies. A representative of the ABPI asked what message is sent by investing in research, but new products not being bought. Dorrell stated that there is the argument that products are developed and then there is slow takeup. Nice tested new procedures to ensure they delivered health gains assessed through quality life years. It is the job of the pharmaceutical industry to sell the benefits of their drugs. On people taking responsibility around their own health, Toynbee stated that diabetes is becoming an epidemic, but this condition can be controlled. It is perverse and odd that the Government is working with drinks and fast food companies. A representative of Baby Milk Action asked about conflicts of interest in the new system, to which Toynbee stated that McKinsey and KPMG are involved in commissioning and they would favour the private sector. GPs had a conflict of interest as commissioners. Dorrell stated that commissioning groups would not be able to award contracts to groups involving members without the regular processes being in place. Conflicts of interest are something the system always needs to be vigilant on. There is a requirement right across the public sector that people declare conflicts of interest. This is not difficult to recognise or enforce. In summing up, Dorrell stated that this is a system-wide challenge, and change is needed in the way care is delivered. Disruptive innovators and measured risks are needed. Toynbee stated that bold and imaginative ideas need to be set up as proper pilots, so money flows in the right way from the right silos. She pleaded for no more reorganisations of the NHS.