Turning government on its head – we hope so

To coincide with the publication of Liberating the NHS, the Department of Health has published its departmental priorities in the form of a Structural Reform Plan.  SRPs are required by the Coalition Government from all government departments.

Head stands

SRPs are designed, in the word’s of the DH one,  to turn government on its head, taking power away from Whitehall and putting it into the hands of people and communities. Once these reforms are in place, people themselves will have the power to improve our country and our public services, through the mechanisms of local democratic accountability, competition, choice, and social action.

This will be a neat trick in more than one sense of the word if it can be achieved.  We hope it can, because the first priority in particular strikes a strong chord with us about user participation and control of public services.

New priorities

1. A patient-led NHS –  Strengthen the patient’s ability to exercise extended choice, to manage their care and to have their voice heard within the NHS

2. Shift resources to promote better healthcare outcomes – Shift focus and resources towards better healthcare outcomes, including national healthcare outcome measures, patient-reported outcomes and patient experience measures

3. Revolutionise NHS accountability – Create a long-term sustainable framework of institutions with greater autonomy for doctors and nurses, and greater accountability to patients and the public, focused on outcomes

4. Promote better public health – Promote better public health for the nation by centring the Department’s focus on public health, developing a clear strategy and partnering with the voluntary and private sectors

5. Reform social care – Enable people needing care to be treated with dignity and respect; reform the system of social care to provide much more control to individuals and their carers, easing the cost burden that they and their families face

Two observations

First, why have we had to wait so long for something like this? These are the obvious things for a government department responsible for health, well being (public health) and social care to be doing in the first place! Let us hope there are enough talented and committed people left when the department is slimmed down to achieve them.

And an elephant warning

Second,  priority 5 about reforming (adult) social care will turn out to be the hardest to achieve. It is the elephant in just about every room you care to enter.  There is no consensus on form or funding.  That was amply demonstrated by the pre-election squabbles about funding processes and affordability.

The Coalition Government has promised a commission on social care to look at all the options. We know what these are likely to be of course.

There should be a government “vision for social care” by the end of this year, with a white paper in 2011.  The Social Care Commission, when established, will report within 12 months on social care funding options.  The White Paper states: The Commission will consider a range of ideas, including both a voluntary insurance scheme and a partnership scheme. As a key component of a lasting settlement for the social care system, we will reform and consolidate the law underpinning adult social care, working with the Law Commission.

We wish this well.  But if you thought GP commissioning was going to be a punch-up, just wait until we really get into social care funding and provision for a burgeoning older population and the many more people with disabilities who are living for much l0nger.

That will really be the main event.  Tickets available from the usual outlets very soon.  Book early for a ringside seat.

Liberation root and branch style

Liberating the NHS the new Health White Paper on “equity and excellence” could turn out to be, in Chris Ham’s prophetic words today, the “biggest organisational upheaval in the health service, probably, since its inception”.  This is about England only of course: the contrast with the other three countries in these islands will now be even starker.

Shaping the new order

Speaking in the Commons this afternoon as the document was published, Secretary of State for Health Andrew Lansley said his objectives were putting patients right at the heart of their care, putting clinicians at the heart of decisions about services and achieving health outcomes comparable of our neighbours.

We are to have an outcomes framework identifying what the health service should achieve and it will be up to the professionals (in collaboration with the public and patients if Lansley is serious about “no decision about me without me”) to say how it should be achieved in each part of the country.

Some of the other highlights of the new order include:

• A payments system that acts as a driver for quality, safety and integrated care not just a reward for activity (very welcome)
• Decision making as close to patients a possible, including patients with long term conditions having budgets (we hope for health AND social care combined) to make real choices about their care.
• Real, local accountability: Local Authorities will agree local strategies to integrate NHS, public health and social care together.  (fine, assuming councillors rise to the challenge and there isn’t likely to be extra money for cash-strapped authorities)
• Consortia will commission NHS services in line with the local health plan agreed with the local Council; this is how GPs will lead bottom up redesign of services:“GPs are senior professionals in public service and paid well for that.” No opting out.
• Patient choice over treatment options, including the consultant-led team that treats them, based on a torrent of information to guide informed choices
• Choice of GP practice and  power to control our own patient records. (no practice boundaries)
• Patient voices will be heard and acted upon by Healthwatch as a national body working through local healthwatch incorporating the current LINks (across health and social care which is essential)
• An English NHS “liberated from command and control”, including all NHS Trusts to be Foundation Trusts with power in the hands of their employees and users: “Our ambition is to create the largest and most vibrant social enterprise sector in the world.” (could help with getting assets off the government’s balance sheet and sort the pensions issue too)
• Any willing provider in the health care marketplace, provided they deliver to NHS standards and prices
• A more powerful Monitor as economic regulator and CQC as the guardian of safety and quality standards
• The NHS Commissioning Board holding the national GP contract, managing performance, allocating resources to commissioning consortia and leading specialised commissioning (big job all of that, any applicants on the horizon?)

Liberation is a double edged sword

MAC’s initial reaction to all of this – our deeper thoughts are for later –  is that what Mr Lansley is proposing  - and the devil will be in the detail of the coming consultations and the autumn Health Bill – could certainly be “liberating” both in an innovative but also in a chaotic sense (think Pandora’s box)  - and probably at the same time.  The phrase “constructive discomfort” comes to mind.

But there’s a catch. The NHS in England must save recurrently some £20bn by 2014 - “every penny saved will be a penny reinvested for the benefit of patient care” Mr Lansley said. That takes many steady eyes and hands on the job and some well placed voices are wondering if now is the right time to pursue wholesale root and branch change which will be very distracting in our largest and most expensive public service? Managers fashioning lifeboats for themselves may have concerns other than achieving efficiency savings.

Cromwellian thoroughness and speed

The reforms to commissioning and accountability aim to be Cromwellian in thoroughness and speed.  Andrew Lansley seems to be taking Tony Blair’s approach further and faster than anyone thought possible, but the difference is there seems to be a map this time.  Our modern day “major generals” (aka Strategic Health Authorities)  are being marched off to the Tower awaiting termination  - or as Mr Lansley termed it “disempowerment of bureaucracies” – by 2012, to be followed by PCTs by April 2013.

As we move towards then, will the crowd be shouting “behold the heads of tyrants” as we breath the free and pure air of GP commissioning, or will we just be too distracted to care?  And will there be anyone left in PCT land by then to turn off the lights, cancel the milk and put the cat out?

A long hot summer for user and citizen engagement?

The budget sparked a debate  about postponing retirement and getting your pensions.  Elder citizens and users who are involved in public engagement must be heard in any such  debate about retirement ages and reform of the job market. They frequently form a majority  of volunteers in citizen participant groupings and all too often get precious little thanks for that. Instead they are lumped under such derogatory labels as the ‘usual suspects’ with their (majority) presence seen as proof of a lack of diversity and a narrow approach to inclusion. It may be that such unworthy thoughts may even have flashed on rare occasions through my and fellow partners’ minds.

Not just valuable but vital

Only to be dismissed at once when at a recent training we did for Wandsworth NHS we met active and interested older volunteers who were a strong reminder of the value of this resource. As people often tasked to set up user panels as well as train them,  we readily acknowledge that many a participative venture would collapse without the time, energy and ideas that the older involved and retired citizen brings to the table. Is the prospect of working beyond the current pensionable age  a threat to this resource? We say no so long as we get the flexibility in the labour market that encourages part-time working. The new volunteer in this context would have a wider set of choices between paid and unpaid work which may well enhance the chances of their participation and at the same time increase the value of that contribution because they remain connected to the wider world through their paid work.

Eight New Laws of LINks

Certainly when we look at any form of future development for LINks, no progress would be possible without good quality people being ready and able to serve on and contribute to them. The elder community will remain an important pool of recruits. Andrew was very gung ho about LINks in his piece. He wrote that LINks must not only survive but take on a more robust role. To that end, he promulgates eight news laws for LINks – essential reading for policy makers we would say.

Reorganisation – flavour of the month

Reorganisation – how fast, how far, how good – crops up in almost everyone  of our blogs. Caroline Millar writes 12 years as a parent have provided many an example of how change gets sneaked through in the summer. Leading the charge for change in education, is the new Secretary of State for Education. Glinting in the sunshine of his new powers like the granite of his native Aberdeen, Mr Gove is granite-hard in his resolve to create Academies asap. In doing so he seems very ready to dump any commitment to consultation in his rush to deliver. He is of course ready to consult later when all the important stuff has got done. Why are citizens cynical about consultation do I hear you ask?

Trust the Teachers and GPs

Having identified  bureaucracy as the enemy of local change, local authorities in education and PCTs in health are being bypassed in favour of teacher and doctor power. Parents are also being urged to get involved in schools but the knowledge that entry to ‘their’ school will probably be by lottery  so their own children may not get in, is a bit of a bummer. However as graduates of the consumer movement in a number of its manifestations, three MAC partners have a superstitious reverence for the power of Young and so cannot dismiss entirely the chances of success for y0ung Young channelling his dad’s influence from beyond the grave to create a new school in West London. (It is an article of faith for all consumerists and others in the field of social policy generally that  ‘Michael Young later Lord Young of Dartington was the greatest British social entrepreneur of the second half of the 20th century’. Discuss using one side of the paper only).

GPs working within consortia are going to be the new commissioners of health and social care services. We have two immediate concerns. The first is the very uneven record of GPs in setting up effective and credible patient participation bodies. Secondly, our work with commissioners of long term and not so long term neurological conditions makes us very wary about GPs being able to take on this complex and often neglected area of clinical and social care practice. Andrew discusses his reservations in a head to head with Lynn Young of the RCN here.

More substantively, his piece Neuro Knees Up or Knockback? raises important questions on how best the Third Sector and in particular neurological organisations can safeguard what we know is a considerable investment in making the best of the commissioning system in place now. Reform threatens to waste this effort and set back their work in improving care for people with neurological conditions.

MAC’s Eight New Laws of LINks – and an acknowledgement to Dr Einstein

Albert Einstein defined insanity as doing the same thing over and over again and expecting different results.  It’s a curse the new Coalition Government must avoid when it gets around to considering its plans for Healthwatch in England and what it intends doing with Local Involvement Networks (LINks).  Scotland, Wales and NI should be free within their devolved administrations to retain, improve or amend their own arrangements for user engagement, complaints and redress processes.  There is much to learn from each other about how to do engagement and participation better across public services.

MAC takes the opportunity in advance of the Health White Paper due in early July to contribute its ideas to the developmental process.  We have ideas about what LINks should do in future and about their relationship with Healthwatch and its functions.  Healthwatch funding should be entirely separate from LINk funding and the latter must not be raised or top sliced to create Healthwatch in England.

Some details are emerging about what the Government’s model for Healthwatch for England might be and what relationship it might have with Local Involvement Networks (LINks), now into the final year of their three year contract.  We have no doubt that LINks must survive and be developed to take on a more robust role across health and social care.

Now read on.

1. Integrated statutory framework.  Healthwatch England and LINks must operate within an integrated statutory framework bringing together involvement of service users, carers and the public and also embodying their rights including complaints and redress.  We are not talking about tinkering with the current fractured system in which most people don’t know how to have their views listened to or how to make a complaint about health or social care their receive.

2. Accountable to Local Authority. We wonder what  the proposed Healthwatch role about providing “leadership to LINks” might mean?   It should not be code for performance management.  Each LINk should be accountable to its sponsoring Local Authority according to a national contract and with sufficient funding to carry out its role in the local area.  Possibly it means Healthwatch taking on the function of the short-lived National Centre for Involvement?  That would be a positive move, by promoting and sharing good practice.

3. Brands  spanning health and care. Healthwatch needs renaming because it is too narrow and sounds like a regulator. “Carewatch England”, though not ideal, would be our choice, because care in its broadest sense encompasses both what the NHS does and what the social care system does. What matters more than a name is this -  the body must not take a medicalised approach: people using health and care services are about much more than being patients (maternity services users for example).  Members of the public have an equal claim to have their voice heard: patient experience is one thing; public involvement quite another and LINk can and must do more of both.

4. Statutory health and care remit.  LINks already have a statutory health and social care remit – that is right and it must be strengthened.  Above all, LINks must not be pruned back to a health-only remit or even one that focuses only on the NHS.  In a pluralistic economy, LINks must continue to be able to enter and view any and all facilities and services being used by publicly funded users – they must go where users go.  Their relationship with the inspecting bodies, particularly the CQC, also needs revisiting and smoothing out.  LINks should have synergistic relationships, not competitive or duplicative.  Enter and view should be sufficient powers for LINk – they are not meant to duplicate what the inspectorate(s) do but can already respond to concerns raised by members and from the public by making visits including unannounced ones.  There needs to be good practice enter and view models that all LINks can follow, including what happens to issues which LINks uncover and then refer to their Council’s OSC for action.  Evidence about this is lacking and Healthwatch should have a remit to uncover, assess and publicise what is happening and raise LINk standards.

5. LINks and OSCs.  LINk in many areas has a good working relationship with the local authority’s overview and scrutiny committees.  In many areas health and social care are combining into a single Adult Care and Health scrutiny body.  It should be taken as read that the LINk as a statutory body will have rights to receive all papers, attend all relevant meetings and speak at health and social care OSC meetings in addition to their existing rights to refer matters to the OSC.  But that needs to be spelled out in guidance or it may not happen in many places.

6. Bring coherence to complaints across health and care.   Since April 2009 there has been an integrated and (at least in theory) simplified complaints system operating across English health and social care.  But this is one of the best kept secrets we know of. Many NHS bodies are complacent about complaints handling and consistently miss targets for providing responses and resolving issues. The complaints and redress system must be made more coherent. But this does not mean that LINks should become involved with complaints handling or advocacy services, though of course they can and should signpost people to where they can get such help.  Complaints handling can easily turn into confrontation.  Healthwatch England’s proposed role to “investigate and support complaints” needs very careful elaboration. We do not want the old intermediate tier of complaint handling undertaken by the old Healthcare Commission revived.   Users got a poor service and the handlers drowned in the paperwork and procedures.

The role of the Ombudsman on the one hand and local resolution on the other should not be weakened. But we believe much could be done to publicise the system and to facilitate people to find their way through it.  Healthwatch could be the independent body which commissions and manages complaints advocacy services (ICAS) for consumers.  The local or regional presence for Healthwatch has not yet been specified; perhaps the White Paper in July will throw light on this.  We note that Mr Lansley himself, unlike Earl Howe, didn‘t mention complaints in connection with Healthwatch in his Bromley by Bow presentation, but the issue cannot be ducked.  The current complaints processes are disjointed, difficult to access and not meeting the needs of service users or anyone else.

7. LINks should be host free.  LINk host bodies are coming to the end of their three year contracts.  This model should not be renewed.  The new model for LINk should be “host-free” because introducing intermediary bodies simply obfuscates governance and accountability.  LINks are statutory bodies and should be established as budget holders and employers in their own right, accountable to their local authorities for their performance against national standards and compliance with a national contract.  This means each LINk should hire and manage its own officers and get the service they need to carry out their roles, something most of them are not able to do at the moment because the Host stands in the way. It also means that LINks will need premises, something that should be negotiated with the sponsoring local authority.

8. Relationships between LINks and Healthwatch. The boundary between LINk and the local presence of Healthwatch will need careful thought so that unintended consequences do not result. The relationship should be additive and synergistic, not competitive. Otherwise consumers and inspectors will be confused.  LINk as a membership body is primarily about involvement, engagement, listening and communicating views as well as being eyes and ears about quality of services and user experiences.  Their relationship to the OSC is an essential one to develop.  This is quite different from what Healthwatch might do as a non-membership body, though clearly there is scope for collaboration.   Equally there is scope for developing relationships between LINk and Foundation Trust Members and Governors and between Healthwatch and Monitor’s expanded role as well as the CQC as the principal inspectorate for health and care.  A matrix of consumer focused activity would be a positive outcome.

Doing these things will avoid Einstein’s curse.  We will get different – and better – results from doing things differently.  LINks and Healthwatch have the potential to develop into a synergistic relationship but not one where one controls the other. For LINks, the accountability buck should stop with the sponsoring local authority.   We hope the Coalition Government has the vision to enable that to happen.

Some background for policy wonks

During the 3rd June debate on the Queen’s Speech in the Lords, the Government spokesman Lord Howe said: “We are going to give the public a strong and independent voice through Health Watch, which will be a statutory body with the power to investigate and support complaints.”

No more details were given, but we can extend Earl Howe’s statement by looking at a reply Hull LINk received to its query on what relationship there would be between Healthwatch and LINks in England.   Here is what they were told:

“ There have been three different mechanisms for patients and members of the public to engage and involve themselves in the development of NHS services in less than four years.  We believe that mechanisms for engaging patients in their health services need to endure so that confidence and brand awareness increase over time, and the experience of those who operate these mechanisms is retained.  We have therefore committed to avoid unnecessary organisational upheaval and retain LINks as the foundation of our policies for patient and public involvement in health at a local level.

However, we are concerned that LINks in their current setup are too weak and will have too few powers to command the confidence of patients and the public.  We will therefore give LINks additional powers of inspection, and the ability to act as advocates for patients who complain about NHS services.

We will also establish a national consumer voice for patients: HealthWatch.  HealthWatch will provide support to patients at a national level and leadership to LINks at a local level.  It will also incorporate the functions of the Independent Complaints Advisory Body.  Health watch will have a clear statutory right to be consulted over guidelines issues nationally concerning the care NHS patient should receive, and over decisions which affect how NHS care is provided in an area. “

A third take on this comes from the question and answer session Mr Lansley made following his first speech as secretary of state at Bromley By Bow Health Centre, East London, on 8th June.   Mr Lansley thanked LINks for all their work thus far and said he was not going to reject people who have been involved in LINks as part of his intention to shift power down through the system and put patients in the driving seat.  He said Healthwatch England would channel more power to local bodies so that there could be more independence, more power and greater opportunities to influence the NHS and social care.  He said the Healthwatch model would be made stronger as the policy details around Healthwatch were sorted out.

The May Newsletter: A Spring Fever of Politics and Participation Possibilities

Overcooked Rhubarb Rhetoric

Politicos have gone mad for it – so many of the election issues and debating points are about citizen engagement  and involvement. We have characterised elections as the biggest citizen participation opportunity going although as we pointed out in our  blog straight after the first TV debate with the audience silent and speaking only when spoken to, the politicians and their minders are playing to the old rules of participation. ‘I speak, you listen and thanks for filling the hall’ is the old discredited recipe for engagement filling the national house with the stale smells of overcooked rhubarb rhetoric. The twelve blog pieces MAC partners  have put up on our site since early March offer fresher and more vitamin-rich fare.

Owners vs Users?

We started by tackling the themes of ownership – should public enterprises be run like John Lewis? We got a piece from a John Lewis lifer - Andrew MacMillan had 28 years there – to explore and welcome the possibilities. We followed this with a look at the crucial differences that have to be acknowledged by an organisation that seeks to involve consumers. Are they being asked in their role as owners or as users?  Not sorting that out contributes to the bad press about participation not cutting it in the real world where tough decisions have to be made. Public discussion on the topic does little to clarify this with an editorial in the Guardian on 12 March getting confused about partnerships and mutuals. Caroline Oliver of Good to Govern makes the point that participation should not be something that swims into the political consciousness at election times but has to be a feature of all our taxpayer owned organisations – all the more relevant in a context of difficult choices about budgets. Love low taxes, hate poor services. Owner/ funder: user/ spender. Tough call illuminated by a comment from Colin Adamson who like other MAC partners is walking the talk as an engaged user and  finds himself Chair of the Company that manages his block of flats. It is hard to create the balance between the job of  keeping the place in reasonable nick and the wishes of leaseholders to keep the service charge as low as possible. (Scary stuff and the search is on for decent directors’ insurance – a definite downside to calls to be involved in modern Britain is a fear of the consequences of stepping up and being counted where ‘counted’ may actually mean ’sued’?)

Practitioners Not Tribes

The phrase was Andrew Craig’s writing about how we can improve the quality of healthcare. To abandon the defining role allocated by the tribe – be it labelled patient, nurse, clinician, parent, teacher – and participate in the achievement of outcomes is to focus on the end not the means. Andrew made the point that the party leaders when talking about heath confused the means (healthcare) with the outcome (health itself). Andrew is a big fan of one way of working that will break down the walls around each tribe’s reservation – Total Place. This will begin to tackle the ‘unjoinedupness’ of local public bodies and offers a vision of all uniting around agreed outcomes. Can we get past the old adage that ‘culture eats strategy’? The Treasury thinks the pilots went well but a consultants report talked of the struggle to get things done. It certainly needs doing  – a point discussed further in Andrew’s piece about individual care budgets and how that assumes healthcare and care services working together to a common end. How will that be put into practice after the election – will it work the way the manifestos say?

Educators’ Tribal Reservation – No entry for Parents?

Is this what is going on in schools? Caroline Millar points out how parents are at one moment excluded and the next supposed to be running their own schools. She went to the launch of the Progressive Education Network in February where the dread word ‘parent’ was not mentioned for the first 45 minutes. Now as she points out parents are being urged to exercise their choices by setting up and running new schools – a choice that only 5% of parents according to an Ipsos MORI survey want to exercise.  The desired outcome as Caroline argues in her April piece is a good education and she worked hard with other parents and fellow governors to improve  the one her children were already attending. What was depressing was how little parents’ voices were listened to  at the time they first brought up the 15 key issues identified much later by an ‘official’  Ofsted report and only then acted upon. Caroline’s perspective encompasses both the teacher and the parent – she taught at Kilquhanty an early and real ‘Free School’  in Scotland set up in 1941. Caroline was not there right at the beginning but remembers the words of the founder and educational visionary John Aitkenhead about the consequences of choices. His view of Freedom was simple:

“You are free to jump into the water, but you are not free to stay dry.”

Jump into our blogs and enjoy getting wet.

Aspiring Prime Ministers should address hard health choices not services

As an example of engagement and participation, last night’s  “leaders debate” failed.  If MAC tried to organise a public participation meeting with these rules – “please sit there like dummies and say nothing unless you are asked” – we would be lynched. Our only hope of escape would lie in the fact that nobody would have bothered to come  to such a rule-bound event.  Going through the transcript and watching the live action (thanks BBC IPlayer) what stands out is the lack of interaction with the studio audience.

The first – and only -question relating to health didn’t come until very near the end, so perhaps the NHS is not such a burning election issue after all?  From a nurse, it focused on our ageing population, new technology and drug costs.   Did the aspiring PMs answer the question?   Of course not.  Once the platitudes about loving the NHS and wanting to keep more people in their own homes not care homes  and pay for all new drugs were out of the way, the fairly well mannered exchanges were not about health at all but about hospitals and numbers of nurses and cancer drugs.  That’s confusing healthcare services (the means) with health itself  (the ends).   The public deserves better than this.

We can have whatever level of healthcare services we like,  provided that  people through their elected representatives are willing to pay for them (and assuming we are willing to forgo paying for things like Trident, schools and motorways).  But just spending money on services does not mean health will be improved or protected or, more importantly, that the yawning gap of health inequalities between sections of the country and groups within the community will be reduced.  Doing that needs shrewd public health driven strategies linked to skillful disinvestment and reinvestment to achieve savings and service changes.  The public rarely is included in those debates, but it cannot be left out this time. We are the owners of the NHS after all – the NHS Constitution says as much.  The state is just the custodian of our resources and owes us the duty of good stewardship.

To do what needs to be done, the level of health literacy must rise. The linkages between health, employment, education and overall social and environmental well being must be clearly understood and reflected in policy and action. Locally MAC is working with our commissioners to deliver a “Training to Make A Difference” programme to a diverse range of people with long term conditions so they can make effective contributions to decisions about the services they use.  This can work but it needs sustained investment  and is not a quick fix.

“Never let a good crisis go to waste” should spur us to think about ends rather than squabbling over how to pay for the means.   Pause and consider this: what would we do if we had to create a national health service “under canvas”  from the 7^th of May without the existing infrastrucure?  A good place to start would be with “zero planning” assumptions as well as zero budgeting and then see what is really important in terms of making a positive difference to health (health gain) and wellbeing and identifying the resources to apply to that objective.  Our present NHS was not created for that purpose and its inadequacies make that obvious.

NHS and social care expenditure is bound to be very much less very soon regardless of what politicians say.  All English commissioners are agreeing eye-wateringly challenging savings plans as I write this.  These will not be achievable without public and stakeholder consent.  Engagement in the process must precede implementation, not follow it.  The “Save Our XXX” placards will soon be waving.  Waiting in the condemned cell until the money tap is simply turned off and the savings are made by crude cuts is not an attractive option.  Ask the Greeks what this feels like. They are about to have the IMF walk through the door axe in hand.

There’s no silver bullet to stop the money going down the drain – but there is lots of “silver buckshot” that’s worth firing.  It would help to start by doing these things:

• pool the budgets between health and local government (Section 75 shows the way)
• focus on a “total place” approach that means what it says
• merge the staff teams and managements
• eliminate the duplicated overheads and rationalise the estate
• share the back office functions
• integrate the strategies and manage demand through primary care
• give people with long term needs realistic integrated budgets to do things for themselves
• and across the board emphasise a preventive approach that is straight with people about individual actions having consequences and entitlements going hand in hand with responsibilities.

That’s not nannying, far from it. That’s laying down a social contract for wellbeing that local people can understand and will want to influence because it is about what happens where they live and what happens to them and their families. Health literacy and active citizenship can be scaled up, but  they must start at the local level.  If we and our leaders don’t learn that lesson, the hard choices we have to make will not be addressed and the next PM may be ringing the IMF sooner rather than later.

The individual budget bandwagon is rolling; who’s got the map?

Labour

A quick browse through both Labour and Conservative manifestos – and what will the LibDems effort bring? – reveals a bandwagon rolling about personalisation and individual budgets.  Here are some excerpts:

Labour –   Everyone with a long-term condition, such as those with diabetes, will have the right to a care plan and an individual budget. [page 4:4]

Conservative – For people with a chronic illness or a long-term condition, we will provide access to a single budget that combines their health and social care funding, which they can tailor to their own needs. [page 48]

Very similar sentiments, but of the two, the explicit joined-upness of the Tory vision has the edge.  Health and social care is – as MAC has repeatedly argued -  a continuum for older people and those with long standing health problems.  It is only a bureaucratic and funding anomaly that keeps them separated anyway, so it is wrong to perpetuate this divide in funding needs that stretch across the health and social care sectors.  Unified – and adequate – health and social care budgets are required.

Momentum towards individual budgets is welcome, but it would be good to know someone had a map of where all of this might lead.   We look to Third Sector organisations to respond to the manifestos with their views of what a personalised future with unified budgets across health and social care might look like.

Health Act rag bag delivers part of the real prize

Health Act Rag Bag

Almost unremarked in the rush of bills getting  the Royal Nod on Friday  the 13^th was the rag bag of measures collectively known as the Health Act 2009. Tucked away among new powers to strengthen tobacco control; to place a duty on all NHS bodies, private sector and third sector providers of NHS services to have regard to the NHS Constitution (more on that in a later blog); to deal with (whisper it) failing Foundation Trusts; to require (largely meaningless) “quality accounts” from NHS bodies and to reform pharmacy services is the provision to give money directly to certain patients so they can obtain their own health care.

It’s Getting Personal

But it isn’t as simple as it looks – the consultation on the regulations and guidance is pretty daunting.  The real problem is that this will deliver only half of the prize that should really be on offer:integrated health and social care individual budgets reflecting the real level of user and carer need.  This is going to be big in coming years given an ageing population and more people with long term conditions surviving for longer periods with better quality of life.  How many?  The think tank Demos At Your Service report estimates 1.5m people in five years will be controlling personal budgets for health and social care.    When this happens, public services will never be the same.

The progress in freeing up NHS money so it can flow direct to individuals for this purpose is welcome (NHS money can already be handed to third party organisations to spend on behalf of individuals) and it evens the scorecard with what is increasingly common practice in social care. In fact, the consultation on the health care budget regulations largely proposes to mirror existing good social care practice.  If this is a hint that the two channels of care services are converging then we welcome it.

If our public services could just get their acts together about this we might see some progress towards the real prize.  David Cameron had the right idea in his recent statement on health priorities earlier this month when he included as part of a reform of long term care that “budgets combining social care and health care funding for people with long-term conditions will be rolled out.”

People Powered Public Services

The latest report from NESTA*  The Human Factor provides the evidence about moving to “people powered public services”  which could save billions. It should be required reading in PCT and Local Authority boardrooms as well as by political party strategists. The word is that Andrew Lansley likes this approach.   Both parties are making noises that the boundaries between health and social care services are going to be intentionally blurred in the near future.  In that light, keeping separate budgets for healthcare and for social care is simply perverse and discriminatory against the very groups who are meant to benefit.  It perpetuates an impediment to integrated services which goes back to 1948.  It really is time to come into the 21^st century with how we commission and provide public health and social care services for our increasingly complex and diverse population.  That’s the challenge MAC would like to see all parties grasp as the election temperature starts to rise.

*NESTA is the National Endowment for Science, Technology and the Arts

The November Newsletter

Dread Moment, Dead Time – the Roots of Laughter and the Prompt to Action

I was in the queue at the Post Office – two positions open for business; 12 people in the queue; having to pay £5 for special delivery because of strike. The message on the QTV? ‘The only real laughter comes from despair’ attributed to Groucho Marx. Nothing could have better fitted the mood of existential gloom at the prospect of 20 minutes queuing while South London people sort out their complicated lives clutching half-filled-in forms and expired passports. None were laughing. It was the most apposite message I have ever seen on that medium but the best was yet to come two seconds later with the name and location of a photocopying shop new to me and just up the road. The ad worked – 20 minutes later I was in there and their sales figures leapt up by 0.72p.

Partners’ Prose

Schools

Of course had I been connected to the internet. the time in the queue would pass in a flash because I could read the Partners’ blog entries in October and November. Caroline Millar sends politicians to stand in the corner for wilfully getting the important Cambridge Review wrong.

It seems to be open season on schools and the question of how they should be run and who should run them. Caroline documents the candidates in some detail in the following terms:

“whether it be local authorities, faith groups, used car salesmen or aspirational lasagna-eating anxiety-monkeys who are running the schools of the future, it should be a requirement for all of them to demonstrate that they know what their pupils, parents and local communities think of them and to show that they are responsive to their needs.”

Read the full post to see where they all come from.

Governance

Val Moore updates us with tales of a Norwegian state pension fund seeking to persuade large American concerns of the advisability of separating the post of chief executive from that of chairman – a central tenet as it happens of Policy Governance®. Val had recently attended one of a series of workshops being run by Caroline Oliver and the UK Policy Governance Association and this separation of function and titles still seems to be causing problems for many organisations.

Val wrote

“Many of these organisations are struggling to see the unique role of the Chairman and Board and want to avoid that well known situation where the Board usurp the role of the Executives and the Executives second guess the Board.  Policy Governance separates the two roles and maintains that the Chairman and the Board are ‘owners one step down’ and not ‘management one step up’.  This thinking frees the Board to concentrate on the ‘ends’ or goals of the organisation and to allow the CEO and executive team to work out the ‘means’.”

Politicians’ promises and social care

Ends and means were very much part of Andrew Craig’s piece musing on how strange it was

“that with little over a month to go for people to have their say about the government’s social care proposals for England, the Prime Minister pulled a monster rabbit out of his capacious hat which made roadkill of the consultation process.  Mr Brown pre-empted discussion by giving a personal care pledge to adults under 65 -  later clarified as also extending to younger disabled people aged 18-64 needing personal care at home.  That’s a lot of people and a awful lot of bawbees, Gordon, even if the Government is still around after 2010.”

If the consultation is to have any useful effect, it should provide some insights into what Andrew identified as the three main issues around social care:-

• First and foremost, we need one, integrated system of health and social care not two
• Second, the social care debate must be widened to include younger adults with disabilities and chronic conditions and people who care for them
• Third, while raising the universal standard of social care we must reclaim the Beveridge principle of individual initiative to make extra provision.

Complaints – Opening Up on Complainant Satisfaction

Back to where we started with a moment of existential despair in a Post Office queue – the mood seems right when comtemplating the Kafka-esque world of a complaint about service at our bank. We take a look  at the experience of having a problem with banks, specs and teeth – and no the NHS does not feature in any of them. The world of the banking back office and that modern contradiction in terms ‘the customer service team’ – neither a team or much to do with service -  and how best intentions and efforts can still go wrong even when all are trying harder than Avis.

But we finish on a good note – if you have a complaint about your private dentist’s service, find your way to the Dental Complaints Service and your complaint stands a good chance of getting sorted according to some new data. Well done Derek.

Broon’s Care Bunny – Trick or Treat?

Broon’s Bunny makes roadkill of consultation?

Was it a conjuring trick to thwart the consultation or just a soundbite one has to wonder?  We find it strange that with little over a month to go for people to have their say about the government’s social care proposals for England, the Prime Minister pulled a monster rabbit out of his capacious hat which made roadkill of the consultation process.  Mr Brown pre-empted discussion by giving a personal care pledge to adults under 65 -  later clarified as also extending to younger disabled people aged 18-64 needing personal care at home.  That’s a lot of people and a awful lot of bawbees, Gordon, even if the Government is still around after 2010.

Bunny Distraction

After the Brighton rabbit trick, is there anything still to consult about?  The King’s Fund was bemused but thinks the devil will all be in the detail.  No doubt it will, but the bigger problem is that rabbits out of hats don’t make good policy. ”Bunny distraction” is a disincentive to engage with the consultation.

How to fund social care costs as our population ages and more of us survive for longer could hardly be more important to all of us, yet most people outside the usual interested parties are only dimly aware this debate is even happening.

National Care Service and funding proposals

At the heart of the proposals is the establishment of a “National Care Service” providing all people with needs above a single England-wide threshold with access to some public funding for their care in older age: a minimum of a quarter to a third of the cost, rising to full support for those on the lowest incomes.

Three options are proposed for how people might fund care costs not met by the state:

1. A partnership model under which individuals are left to meet their care liability themselves. The Green Paper says that while average costs for people over 65 would be around £20,000 to £22,000 per year, those with the highest needs, such as people with dementia, could still face significant costs of £100,000 or above.

2. An insurance model under which people would be invited to enrol in a state-backed insurance scheme – either run by the state or private insurers – and then get all of their care costs covered. The Government estimated that people might need to pay £20,000 to £25,000 into the scheme, protecting those with higher needs against prohibitive costs.

3. A comprehensive model under which all people over 65 would be compulsorily enrolled in a state insurance scheme. This would reduce premiums from £17,000 to £20,000, because the risk pool would be maximised, but people would need to pay regardless of whether they needed care or not.

1 and 2 are nonstarters.  If it’s non-compulsory, those that are likely to need it most won’t bother.  Think about National Insurance contributions - no one would seriously suggest that should be optional.

Accommodation costs – the kicker jacking up the price

Accommodation costs in care homes would not be covered by these arrangements, but these costs would still be met for those with the least means, as now.  But there is a “fix” proposed for this – “care now and pay later”,  in effect  from beyond the grave.  Property owners could have their hotel costs for care met now, with cost recovery from their estates later on.  If this were nationally consistent and  transparent, it could work and should be seriously considered, we think.

Consistency please

Councils are notoriously inconsistent in setting and applying their eligibility criteria for social care.  Many people with needs judged to be low or moderate have been dropped off the eligibility list as resources are concentrated on “serious” need.  The Green Paper proposes a remedy in the form of a consistent care system with  a single national eligibility threshold, under which people who had difficulty with three or more activities of daily living would be covered. People would be able to move between areas and take their eligibility for care services with them, unless their needs also changed. The government would decide what proportion of someone’s care costs would be met by the state and what by the individual, rather than allowing councils to determine charges for non-residential services, as they do now.  Provided this was equitable, we think a move to national consistency would be welcomed.

There are things that could be done now

Are these proposals the future for adult social care in England?  They are one possible future, but not the only one.  According to the Joseph Rowntree Foundation’s ongoing research programme “paying for long term care” there are a number of successful current models of long term care arrangements for older people that could be rolled out more widely.  These should not be ignored in concentrating only on the Government’s options.

Get down to the basics about social care

Over and above commenting on the details, we think there are three things to be emphasised in this consultation:

First and foremost, we need one, integrated system of health and social care not two. A “National Care Service” that is insurance funded will always be problematic compared with a taxation funded National Health Service.  Why not combine the two into a universal service with a mixture of central taxation and insurance-based funding?  Service users don’t see the rationale for the division between health and social care anyway.  It is illogical in terms of how people with complex needs live their lives and need to access services.  Isn’t having a seamless service what we are supposed to be striving for?

Second, the social care debate must be widened to include younger adults with disabilities and chronic conditions and people who care for them. Adult social care is not just about elderly people.  Many thousands of younger adults 18-64 need better social care now  - generally at home – and will increasingly do so as they live longer.

Third, while raising the universal standard of social care we must reclaim the Beveridge principle of individual initiative to make extra provision.

We want to see these questions addressed in the responses to the consultation.  So we urge readers to ignore Mr Brown’s Brighton bunny and buckle down to thinking about the real issues around social care in England.  As someone from the government-in-waiting said recently, “We’re all in this together”.   How true.

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