This page shows the latest blog posts from The King’s Fund.
15 June 2017, 11:01 pm
Today is national care home open day. This has prompted me to reflect on how some areas have been successful in joining up health care and residential care to better meet the complex needs of people living in care homes. The best-known examples are perhaps the six vanguards for enhanced health care in care homes, but other areas outside NHS England’s vanguard programme have adopted a similar approach.
In these schemes health professionals work closely with care homes and deliver care on site to address issues around access to and quality of health care. The schemes involve greater input from and regular patient reviews by health professionals – GPs, district nurses, consultants and others – who are matched with specific care homes. Care home staff within these schemes may have additional training and undertake new roles, and many schemes include initiatives such as streamlining information flows at admission and discharge from hospital or greater use of telehealth. The aim is to prevent health concerns or detect them early, enabling people to be treated without admission to hospital, and to provide both continuity and comprehensiveness of care.
I’m especially interested in efforts to join up commissioning. When we reported on the future of HIV services in England, we found that three years after a reorganisation of commissioning responsibilities, many services were still adjusting to change. HIV services are not slow: building up new relationships and processes just takes time, especially when people’s needs, financial pressures and other services that are interdependent are all changing at the same time. Until commissioners agree on a strategy, services can easily fall into planning limbo.
The enhanced health care in care homes model involves ‘collaborative commissioning’ across NHS services and residential care. For example, some areas are working towards common service specifications, based on co-production with service users and an ongoing forum with care homes.
It is likely that the key to getting this collaboration right, has been a shared vision of what good looks like. To create this vision areas have evidence to draw on, for example around using comprehensive geriatric assessment (CGA) to keep people well rather than reacting to ill-health, and guidance from the British Geriatrics Society and schemes such as My Home Life.
Enhanced health care in care homes projects are not as large-scale or high-profile as sustainability and transformation partnerships (STPs) or primary and acute care system vanguards. Nonetheless, they can make a significant difference to people’s lives and shouldn’t be overshadowed. Presentations from our conference in 2016 demonstrated how significant reductions in unplanned admissions can be achieved. Our learning network is sharing experience around work such as falls prevention through pharmacists reviewing medicines within care homes in Leicester and introducing Schwartz rounds to support care home staff in providing compassionate care in Hammersmith.
My impression is that the schemes’ benefits have so far been measured mostly in terms of reducing hospital activity, rather than more direct improvements in the quality of care and quality of life of people living in care homes. It may still be too early to expect evidence of benefit to wellbeing and life expectancy, but that definitely needs to be the direction of travel. In the meantime, measures such as preventing avoidable admissions or delayed transfers may serve as indicators of progress, and are likely to help make the case for spreading good practice. It’s quite possible that many commissioners do not appreciate the scale of avoidable hospital stays and the potential financial savings involved in reducing them.
The role of national bodies in supporting the roll-out of new models of care is critical. At the start of this year, expectations were high that NHS England would act to accelerate the spread of good practice between the NHS and care homes in every area of the country. What happened to that? It was not mentioned in NHS England’s Next steps on the NHS five year forward view and the grapevine has gone quiet. Hopefully now that the restrictions on policy announcements during the election period have ended, this will make its way back on to the agenda.
Evidence is growing that investing in joined-up working between care homes and the community-based health care workforce, such as district nurses and GPs, can save money and reduce pressures in other parts of the health care system. Fully recognising achievements so far, I would lay down a challenge for commissioners in local authorities, CCGs and area teams: how will this growing evidence be acted on? What will enhanced health care in care homes schemes tell us about the will and the ability to invest in out-of-hospital services, as envisaged in so many STPs?
We will be holding another conference on enhanced health care in care homes later this year. My hope is that speakers and delegates will provide some answers to these questions, and demonstrate progress in spreading good practice from pioneering projects, to the mainstream.
14 June 2017, 9:11 am
The Conservative Party’s manifesto proposals for social care – promptly labelled a ‘dementia tax’ by its critics – was one of the turning points of the election campaign. The question now is whether, as a result of that debacle, all proposals for reforming social care are, in practice, a dead letter for this parliament, given the government’s lack of a majority.
The answer is they should not be. The problems in social care, which include the trauma it is causing for the NHS, are not going to go away. It would, however, be foolish to pretend that solving these problems will be easy – as illustrated by the fact that over two decades at least four serious independent reviews of social care and its funding, including a Royal Commission and the Dilnot review, plus at least a dozen Green and White Papers, have failed to produce a settled answer for England.
It is not easy because there is not one issue here, but four deeply inter-related ones. First, how far should individuals and their families be responsible for paying for social care, against how far should the taxpayer meet the bill? Second, a question that sounds similar but is in fact a different one; at what level of need should the state provide, and how generously? Third, how can the much greater integration of health and social care that everyone recognises is needed, be achieved? And fourth – an issue that lies behind all three of those – why do we as a nation apply totally opposite arguments to the provision of health and social care? For most people it is a matter of pride that the NHS seeks to treat everyone equally regardless of means. Yet when it comes to social care, the argument is that the state should not subsidise those with the means to provide for themselves – an argument that (a few prescription charges aside) is never applied to the treatment of cancer, diabetes or the need for a new heart, new hip or pretty much anything else the NHS supplies. It is possible we won’t get to a sensible and settled answer to the first three of these until we have answered the fourth.
The initial Conservative manifesto promise was chiefly about the first of these. How much should individuals (and thus by implication their families) pay, as against the state? Its inclusion was all the more bizarre because the Conservatives had already promised a Green Paper for the autumn, and already had, in legislation – but postponed to 2020 – the Dilnot proposals for a more generous means-test and a cap on lifetime total expenditure. What the manifesto effectively did was take Dilnot’s more generous means-test (by allowing people to keep £100,000 of their assets), drop the cap (set at around £72,000), and throw in the idea that people receiving care in their own home should pay for that care with the value of their home (down to the £100,000 floor). Half-baked is putting it politely – leaving aside the sheer administrative complexity of the last part of that proposition.
So what could the government do? And what should it do? Well, it could go back to Dilnot and meet the cost of that. Several billion pounds over the years which would have to come from tax rises or cuts elsewhere. But while Dilnot tackles the question of how much the individual should pay, it would not in itself increase the quantity of social care provision. That is decided by the needs test – how great do an individual’s needs have to be before they get help? – not the means test. And the ever rising level of need that is required before an individual gets the taxpayer’s help has been one of the key drivers of the current social care crisis. Finding the money to tackle that would be even more difficult if – as some are speculating – the government drops its commitments to end the triple lock on pensions and means-test winter fuel payments for older people.
So what the government should do first, in its humbled state, is reach out across the party divides to seek to build as common an answer as possible to these questions. In practice, if only the politicians could resist shouting ‘dementia tax’ or ‘death tax’ at each other, there has been more communality in their assorted answers to the ‘who pays’ question (including the idea that there should be a cap and that housing wealth will come into it somewhere) than they will publicly admit. And there are at least 20 years of common ground that social care will, one day, have to be sorted. Silence is not an answer. If the government seeks only to stay shtum, social care will come back to bite it, and hard.
This blog was originally published by the Institute for Government
14 June 2017, 9:06 am
Despite the advances of recent years, two recent reports, Women in finance and Women on boards: 50:50 by 2020, once again draw attention to the problems women still face in obtaining senior leadership positions within the NHS and outside it.
Women in finance is about fairness, equality and inclusion for women and men. It is predicated on a desire for gender parity and a balanced workforce because, as the evidence makes clear, this improves culture, behaviour, outcomes, profitability and productivity. However, the current situation in the financial services sector is quite different; more women than men start out in financial services but many women fail to move up the management scale. This leaves almost all the top jobs in the hands of men. The main reason for this, it appears, is organisational culture.
One study conducted in 2016 across a wide range of employment sectors found that unsupportive workplace cultures still present the most significant barrier to career progress for women. Amazingly this was the case for female respondents in the 20-29 age group as well as for older respondents. Gender inequality and discrimination were reported, as were difficult colleagues and managers, bullying, undervalued work, and women feeling that they have to over-perform simply because they are female. Recommendations following this study included building closer relationships between men and women in the workplace, and the provision of opportunities to discuss gender issues experienced within the organisational culture.
Organisational culture (including the drive for a more inclusive approach to leadership development) is something that is currently receiving considerable attention in the NHS. Michael West has led much of the work in this area, and his accounts of the impact of what – in some places – might be described as a macho culture, are deeply worrying. Given that the NHS is made up of a predominantly female workforce, the impact of such a culture is largely upon women. Obviously, in some cases, this includes women behaving less than supportively to other women.
Professor Ruth Sealy’s report on senior women in the NHS makes clear that, despite 77 per cent of the NHS workforce being female, there is still long way to go in terms of gender parity in senior leadership positions. If the NHS Improvement/NHS Employers target of 50:50 representation on NHS boards is to be achieved, 500 more women need to be appointed to board-level positions by 2020.
Despite these reports emanating from very different sectors, the issues they raise are remarkably similar and, not surprisingly, there is commonality across some of their suggestions for addressing the issue. For example, they each call for strong leadership (including positive male role models) or executive accountability for the gender parity agenda at senior leadership/board level, the use of agreed targets and, crucially, mandatory public reporting of progress against targets and gender balance on boards. As the saying goes: ‘What gets measured (usually) gets managed’.
The NHS report also advocates gender-specific learning in NHS training programmes, covering topics such as unconscious bias, management of flexible working practices and specific female coaching, mentoring and sponsorship.
Here at The King’s Fund we are already doing this in our Athena programme and, while Athena focuses specifically on issues facing women, we feel that progress on gender equality will be a catalyst for change in other under-represented groups and a step forward for working with diversity and difference beyond gender.
Our work ‘in the moment/in the classroom’ has involved experiential exercises around difference: in one such exercise we challenge people to consider various ‘labels’ – married, single, divorced, from an ethnic minority, born in the UK, not born in the UK and others – and then to explore what it feels like to be labelled in these ways, what it feels like to be in a majority and also a minority; noticing how it feels to be ‘different’. While this exercise is clearly relatively simplistic, it nonetheless acts as a gateway to a more profound discussion around ‘difference and diversity’ and the resource, as opposed to the threat, this offers for leaders.
Whilst attempts are being made to address the issue of unconscious bias generally in the NHS (see, for example, the work of The Royal College of Surgeons and this piece by head of diversity and inclusion at NHS Employers), in recruitment it remains an issue, despite the need for an inclusive workforce which reflects the diverse communities it serves. Unconscious bias (notably against women) continues to impact many senior leadership appointments both within and beyond the NHS.
Embracing difference forms part of our work on enabling women leaders to discover and use their own resources and talents to handle and transform the cultural challenges that remain in the workplace – and how hard taking on this challenge can be.
9 June 2017, 9:52 am
The King’s Fund is celebrating its 120th anniversary over the course of 2017. In the fifth of a series of blogs looking back at our history, Nikki Smiton looks at the work of the Fund in the years leading up to and during World War II.
Before the creation of the NHS in 1948, the work of the Fund was primarily focused on raising money and public support for voluntary hospitals, which cared for the poor. One of the Fund’s achievements in the years between the wars was the creation of Hospitals Flag Day in 1937. Flag days – when hospitals sold small flags for people to wear to show their support for a good cause – were a popular way of raising funds. Initially each hospital ran its own flag day, but the Fund encouraged hospitals to co-operate with a combined scheme, which was a great success. The first flag day in 1937 raised more than £32,000 (over £2 million in today’s terms) and this increased to more than £78,000 (over £3.6 million today) in 1941 (p 89).
During this period, the Fund also worked to support services provided by voluntary hospitals. In 1937, the Fund set up its Radium Committee; voluntary hospitals frequently appealed for radium (used in research and the treatment of cancer) and the Fund had been involved with the supply of radium to London hospitals for some years. A donation of £50,000 from Sir Otto Beit – a German-born British financier and philanthropist – meant the Fund could set up a radium ‘pool’ from which hospitals could borrow. The Fund even had a specially designed lead-lined car with a safe for transporting radium (p 56). The work of this Committee became more challenging during the war because it needed to ensure that the radium could be contained safely amid air raids and bomb damage.
Before the war, the Voluntary Hospitals Committee asked the Fund to create a centralised scheme – known as the Voluntary Hospital Emergency Bed Service – under which people with urgent medical needs could be rapidly admitted to a voluntary hospital. After the Munich Agreement of September 1938, the Ministry of Health asked the Emergency Bed Service to keep records of available beds and civilian casualty lists should war break out.
On 3 September 1939 war was declared and, initially, the Emergency Bed Service struggled to cope with the challenges that war brought: a 1942 publication describes how ‘during the first fortnight of war it was impossible to operate the Service in the absence of the trained staff on their war-time duties’. Things quickly improved, however: ‘…on September 16th of that fateful year a new staff was assembled at the offices of the Fund and an attempt made to resume routine duties’ (p 88). Throughout the war, the Emergency Bed Service worked alongside the Emergency Medical Service to co-ordinate emergency admissions with both municipal and voluntary hospitals, despite the difficulties that air raids and interruptions in telephone services represented.
Before the start of war, nursing recruitment was high on the Fund’s agenda (p 90), so it set up a Nursing Recruitment Committee and in 1940 opened a Nursing Recruitment Centre in Cavendish Square, London. The 1941 annual report details how the Centre helped more than 4,500 individuals who asked for information on a career in nursing (p 16).
The Fund did not produce many reports during war time but afterwards began again to publish reports that reflected areas of concern at the time. In 1945, the Fund wrote about standards of nursing staff, the employment of domestic staff in hospitals and post-war hospital problems. In the years following the war, the Fund also produced many reports looking at the issue of food in hospitals. Given that rationing did not end until 1954, there was much talk of how to make the most of food available. A popular publication produced in 1943 on hospital diets was followed in 1945 by guidance on menu planning for hospitals (p 8).
1942 saw the publication of the Beveridge report, which led to the creation of the welfare state as we know it, including the establishment of a National Health Service. In the next blog in this series, we will look at how the creation of the NHS changed the work of the Fund.
7 June 2017, 1:09 pm
Our June 2017 quarterly monitoring report (QMR) showed that NHS performance on key access targets over the financial year 2016/17 continued to deteriorate. For the ambulance response time, A&E four-hour waiting time and 62-day cancer treatment targets 2016/17 was the third year in a row that performance was below the standard; for elective waiting times (18 weeks from referral to treatment), it was the first.
This further decline in performance happened in a year when the NHS was trying to ‘do it all’; keep a firm grip on finances while maintaining performance against key access targets and developing new models of care. Performance also deteriorated despite a year of relative plenty for NHS funding, as funding growth in 2016/17 was far higher than it will be over the next two years (under current pre-election spending plans).
It’s worth mentioning here that, though the access standards were not achieved, more than 400,000 more patients received elective care within 18 weeks (from referral) and almost 6,000 more patients received treatment for cancer within 62 days in 2016/17 compared to 2015/16. So, the NHS is treating more patients than ever before, but not enough to maintain the level of activity needed to meet national standards.
To address this, the government and NHS England have decided to focus on attaining the A&E access standard in 2017/18; performance against this standard dipped to 89.1 per cent in 2016/17. The NHS will need to improve aggregate performance to 90 per cent by September 2017 and the majority of hospitals should be meeting the 95 per cent standard by March 2018. The national bodies are adopting a three-pronged approach to achieve this.
First, prioritisation. The NHS mandate for 2017/18 and the Next steps on the NHS five year forward view make it clear that the A&E – and 62-day cancer – standards must be met in 2017/18, while the 18-week elective treatment target is only mentioned in reference to targets being met ‘by 2020’, effectively downgrading it for now.
Second, incentives. NHS hospitals will again, in 2017/18, have financial and performance targets to meet to qualify for their share of the £1.8 billion available from the Sustainability and Transformation Fund. However, in 2017/18 performance will only be judged on whether they meet their A&E target, unlike in 2016/17 when they had to meet cancer targets and elective treatment targets as well.
Third, funding. £100 million capital funding for new triage models in A&E was announced in the Spring Budget. The additional £2 billion announced in the Budget for social care is also supposed to free up hospital beds and, in turn, speed up the transfer of patients who require admission from A&E.
Will this be enough to get back on track? Though performance against the A&E standard improved to 90 per cent in March 2017, fewer than 1 in 10 of the NHS finance directors in our QMR survey were confident the NHS will be able to maintain this performance and hit the interim target. Fewer than 1 in 5 CCG finance leads were confident.
Whether the prioritisation of A&E standards in 2017/18 will work or not, it will have a knock-on effect on elective services. Half of the CCGs responding to our QMR said their financial forecast will depend on delaying or cancelling spending this year, while 40 per cent of CCG finance leads are reviewing or reducing planned elective activity in 2017/18. However, the remainder are not, illustrating that reprioritisation is very difficult once contracts with providers have been signed.
The consequences of the focus on the A&E standard – longer waiting times and waiting lists for elective care – are acknowledged, but the scale of the potential impact is unknown. The Next steps document predicts that the median wait for elective care ‘may move marginally’, but doesn’t go as far as defining what the forecast is, let alone what NHS England would deem acceptable.
But waiting lists don’t shrink on their own accord, every patient on a waiting list will need to be treated at some point. Most patients will continue to wait for treatment to begin but some may find themselves accessing NHS services through other routes if their symptoms worsen while they wait. For example, patients requiring restorative surgery might make additional visits to their GP to review their pain and have additional prescriptions for pain relief to manage this.
And if the A&E standard is met again by March 2018 what then? How will trusts maintain access to A&E services within standards when there is a large backlog of elective work? Does elective activity then become the priority over A&E? Do they compete? And where does this leave the NHS Constitution, which gives patients a legal right to access elective services within 18 weeks but gives only pledges (not legal requirements) to meet the A&E target?
With NHS leaders effectively acknowledging that the service cannot continue to achieve the current set of finance and performance targets, the questions now are: what level of access is acceptable across the full range of NHS services, when can this be achieved and how much will it cost?
5 June 2017, 4:07 pm
In 2008, at the 60th anniversary of the NHS, Kenneth Clarke, the health secretary who introduced the purchaser/provider split into the NHS in 1991 observed: ‘if one day subsequent generations find you cannot make commissioning work, then we have been barking up the wrong tree for the last 20 years’.
Well, we are not quite there yet. But it is clear that faith in the ‘purchaser/provider split’ or in ‘commissioning’– and its accompanying concepts ‘choice and competition’ – as the key drivers of reform is fast dissolving.
The clue lies not just in the Labour manifesto promise, yet again, to abolish the Health and Social Care Act 2012, but in the little-debated section of the Conservative manifesto that promises ‘to review the operation of the [NHS] internal market’ and to legislate if necessary ‘if the current legislative landscape is either slowing implementation [of plans to improve patient care] or preventing clear national or local accountability’.
Leave aside for one moment the revival of the term ‘internal market,’ which virtually no-one has used since the 1990s. It still tells us two things. First, that May’s administration is prepared to legislate on the NHS when Cameron’s was so seared by the experience of getting Lansley’s Act through parliament that any talk of amending legislation was forbidden.
But second, that choice and competition – and with that greater use of the private sector – which many opponents of Lansley’s Act saw as its chief component – has ceased to be a key driver of NHS policy. That has been coming for a while.
In is notable, for example, that ‘choice’ appears 39 times in Liberating the NHS, the White Paper that set out the Lansley reforms, but it appeared only four times in Simon Stevens’ NHS five year forward view, then chiefly around ‘choice of treatment’ rather than choice of provider. Competition appears seven times in the White Paper; not once in the Forward View.
Sustainability and transformation plans emphasise collaboration rather than competition, to the point that some of them– an initial nine or so – will become local ‘accountable care systems’ – effectively groupings of hospital, community and primary care services allied to social care that will have a single budget to provide properly co-ordinated care for patients. As Simon Stevens told the Public Accounts Committee in February that ‘will for the first time since 1990 effectively end the purchaser provider split.’ As he noted at the time ‘this is pretty big stuff.’
That ruffled more than a few feathers. David Hare, the chief executive of NHS Partners (which represents many of the private providers to the NHS) warned that any such change must act ‘within the existing legal framework’ of competition and procurement law. And it is tweaks to that, and to the regulatory framework, that look likely to be the targets of the Conservatives’ review.
So why is this happening?
Well, the original idea of the purchaser/provider split was that the NHS should, arguably for the first time, consciously decide what health care provision it wanted to buy and then purchase it from the best provider – whether from NHS organisations who were to be made more independent by NHS trust status or from the private or the voluntary sectors, which would be free to compete for the business.
The Labour government refined this by introducing a price list for many procedures – ‘the tariff’ – which restored patient and GP choice of where patients got treated; this was accompanied first by the commissioning of independent sector treatment centres as privately run surgical factories to treat NHS patients and then by extending patients’ right to go to any private hospital willing to treat them at NHS prices.
For what was seen as the central problem of the 2000s – NHS waiting times – all this certainly worked: waiting times that were often at least 18 months dropped (broadly speaking) to no more than 18 weeks.
It remains highly debatable how far the ‘purchaser/provider’ split that drove that. There is plenty of anecdotal evidence that choice and competition had an effect and some academic evaluation to support the idea*. But looking at the data overall, it is hard to prove an impact. John Appleby has a neat graph that plots the decline of waiting times against each of the choice and competition initiatives; the line declines steadily, with no discernible acceleration as these changes took effect. Which is not to say that there was no impact. There is no counter-factual, other than in Scotland and Wales, neither of which embraced choice and competition on any scale, but where the different ways the waiting time numbers are compiled makes comparison difficult. In England the decline in waiting times might have slowed without the choice (and thus competition) initiatives. But, intuitively, it feels more likely that the key drivers were the other tools that were applied – huge amounts of extra money, a regime of ‘targets and terror’ which saw chief executives fired if they failed to hit their ever-tightening target, and the tariff.**
The tariff, however, was far from great for tackling another key issue: how to provide better integrated care for the growing numbers of mainly elderly patients with long-term and often multiple conditions. Furthermore, given the near impossibility politically of closing down health services, choice and competition in health seem to work best when there is a growing rather than a shrinking market – and, despite its relative protection, health has been a shrinking market since 2010 in terms of real spending per head adjusted for age.
So the tools that worked well for the political and service priorities of the 2000s do not work well now, and in some ways they have become counterproductive – encouraging the click of the turnstile at the hospital when better integrated care might not prove cheaper but should prove better for patients in terms both of their experience and outcomes.
There is a neat irony here. Lansley’s Act was seen at the time as taking to ultimate completion the ‘choice and competition’ approach to running the NHS that Labour had revived and re-launched from the Conservative days. Instead the Act has proved to be the high-water mark of faith in such mechanisms.
It is important not to overstate this. NHS England will still be the commissioner for accountable care systems or organisations, if we ever get to them. Or some different form of clinical commissioning groups will technically do the job. They will have to retain the patient’s choice over where they are treated, and they will be able to contract with the private and voluntary sectors and other parts of the NHS when they believe that is in patients’ interests. Any legislation to dilute or remove the application of procurement and competition law may have to await Brexit. And this shift raises more questions than can be addressed here.
But if 25 years of policy is not entirely being thrown out of the window, it is, at the very least, being massively modified. How long, one might wonder, before the wheel turns again and policy-makers start to worry about monolithic provision when one of the accountable care-type systems proves not to be great at the job?
* Also see Zack Cooper in the Guardian
** See Understanding New Labour’s Market Reforms of the NHS and From quasi-market to market in the National Health Service in England
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5 June 2017, 1:00 pm
Two of the five tests we set out for the parties’ manifestos and for the incoming government were commitments to priority for population health and to working with people and communities.
So, how do the manifestos stack up against these tests? An early spoiler: looking for a strategic approach to population health in the manifestos is like looking for needles in a haystack. While there are some policies that will impact on our health, there is far too much missing, and what is there is not brought together into a strong narrative or strategy that connects them, although the Liberal Democrats come closest.
First, a look at what appears as public health headlines in the ‘health’ bit of the manifestos. Labour’s focus is very much on children’s health, including a ‘new index of child health’, a £250 million ‘Children’s Health Fund’, more health visitors and school nurses, and a new child obesity strategy. It also commits to a tobacco plan. The Liberal Democrats say they will roll back public health budget cuts, and introduce a minimum unit price for alcohol (subject to the legal challenge in Scotland), a tobacco levy to contribute to health and care budgets and mandatory targets on sugar reduction. What few commitments the Conservatives make are focused on the NHS, eg, support for community pharmacy to help ‘keep people healthy’, though they will also extend Care Quality Commission inspections to local authority-commissioned public health services.
Second, what do the manifestos include about inequalities in health? The Conservative manifesto, recognises that ‘If you are born poor, you will die on average nine years earlier than others’ but there is nothing explicit on what the Conservatives would do to tackle the connection between disadvantage and health outcomes (with the exception of improving the oral health of deprived children). And there is not much on this topic in the Labour or Liberal Democrat manifestos either. As a whole, it seems that the parties, have either given up on explicit policies that tackle social inequalities in health, or assume that the wider polices in their manifestos will automatically tackle them.
So, third, what about those wider policies such as housing, access to education and work that evidence tells us are so important to population health? The Liberal Democrats are the most direct of all the three main parties, saying they will, ‘Publish a National Wellbeing Strategy which puts better health and wellbeing for all at the heart of government policy’. They also commit to improving air quality (through a new Air Quality Plan, which they claim will prevent 40,000 deaths per year), to legalising cannabis and giving the Department of Heath control for drug policy. Labour also have a strong focus on making it easier and cheaper for people from poorer backgrounds to access education and commit to a new strategy to reduce child poverty. The Conservatives offer National Insurance ‘holidays’ for employers taking on specific groups (such as those with disabilities and people unemployed for over a year). All three parties offer welcome commitments on housing, including on increasing the amount of social housing and on insulating homes.
But let’s look at some omissions. Neither Labour nor the Liberal Democrats challenge the current government’s plans to end the public health grant to local government; an issue we are very concerned about. Labour say nothing about rolling back the public health funding cuts of the current government or to putting health at the heart of all government policies, despite its pledge on this in 2015. This is all the more surprising because the Welsh (Labour-controlled) government has just passed the Public Health Wales Bill, which commits to health impact assessment of all relevant government policies.
Overall, while the Conservative manifesto is the sparsest of all in terms of commitments on public health, none of the manifestos stand up to scrutiny on inequalities in health, or have anything really meaningful to say on the role of the NHS in population health, such as strengthening accountability through STPs. Neither do they offer a compelling vision for leveraging the power of people and communities in creating health.
Whoever wins on 8 June, we will continue to challenge and hold the new government to account for its actions on population health. We will want to see:
- a cross-government strategy on public health (including stronger roles for tax and regulation) and explicit policies on reducing inequalities in health
- protection of, and increases in, public health spending
- a much stronger accountability framework locally for population health (including within STPs) which must include a stronger expectation of the NHS in tackling the wider determinants of health and in the development of population health systems with its local partners
- a greater focus on maximising the contribution of individuals and communities to heath, as Derek Wanless argued for in his ‘fully engaged scenario’ back in 2002, recognising the role of volunteering, social movements and the voluntary and community sector.
If we get that, the election will have been worth calling.
2 June 2017, 10:55 am
You might think that comparing the parties’ offers on the funding of the NHS would be a straightforward job. Surely nothing more than a little arithmetic, based on pounds, pence and growth rates.
Alas no. Though everyone promises more money, the parties start (and finish) counting the extra money from different years, include different elements of health spending and use different methodologies to tot up the numbers. I will try to set out the key measures of what the parties have offered, based on their headline manifesto commitments combined with public and private clarifications to fill in some of the gaps. Taking them in the order in which they were released.
Labour’s manifesto headline is to provide £30 billion more than current (Conservative) plans over five years, or £6 billion a year. This covers all revenue spending on health (ie, includes the NHS, public health, training etc). Of this, some £3 billion will be used to re-instate bursaries for nurses, leaving £27 billion for other services or £5.4 billion a year. Labour has also referred to providing £40 billion over five years – this is the £30 billion plus a further £10 billion for capital spending, or £8 billion a year.
Labour plans to re-open current 2017/18 spending plans, providing an immediate in-year boost to health spending. However, as they have made a five-year commitment starting in 2017/18, it runs out in 2021/22 – ie, before the end of the next parliament. Also, as it is phrased as ‘more than’ the current plan, strictly speaking it becomes tricky in 2021/22, when there is no current plan (the 2015 Spending Review settlement runs out in 2020/21). The Labour Party also intends to end the current pay restraint, which will have to come out of the £27 billion (as each 1 per cent added to pay will cost around £500 million if given to all staff, this soon mounts if applied every year).
The Liberal Democrats’ headline manifesto number is £6 billion more than current plans for health and social care in 2019/20. This is meant to plug the funding gap until two other manifesto commitments kick in: developing a dedicated Health and Care Tax and using the findings from a cross-party convention to review the longer-term finances. As some £2 billion of the £6 billion is meant for social care, this would leave £4 billion for the NHS itself. This pledge also represents an early boost to the NHS, but starting in 2018/19 rather than 2017/18 (one year after Labour).
Most LibDem pledges also focus on 2019/20, the year their tax and spending plans reach their full effect. However, aside from the (many) details – including how income tax increases generate in the UK and how much of that comes to the English NHS – the £4 billion excludes capital spending, which is pencilled in for another £10 billion over the five years. It also excludes the unwinding of pay restraint, the costs of which are likely to be more than £1 billion a year by 2019/20 and will be on top of the £4 billion (rather than coming from it, as with Labour). Like Labour, the LibDems plan to reinstate bursaries for nurses (costed at £488 million a year in 2019/20 and rising after that) and also intend to reverse the cuts to public health spending (at a cost of £90 million a year in 2019/20). These are also additional to the £6billion (for health and care) or £4 billion (just health in England).
Though the LibDems aim for a long-term solution to funding, if there is none, overall spending is pencilled in to increase by 2 per cent in real terms after 2020/21 in line with expected economic growth.
Lastly, the Conservatives manifesto headline is £8 billion more in real terms (ie, unlike Labour and the LibDems, it explicitly protects against inflation) in 2022/23 than is planned in 2017/18. This refers to NHS England spending only and therefore excludes public health, training and other Department of Health budgets – which were cut when this definition of spending was used in the last Spending Review. However, the Prime Minister also committed to an additional £10 billion in capital spending, although – as recommended by the Naylor report on NHS property and estates – not all of this will necessarily come from the taxpayer.
How current spending is increased year by year up to 2022/23 is not stated other than to promise real-terms growth per capita in NHS England budgets. This would result in a boost to spending plans for 2018/19 and 2019/20. As the Conservatives do not plan to reverse the end of bursaries for nurse training, or end pay restraint, neither are relevant in their case, at least if looking at overall spending.
So who will be most generous? On capital spending, everyone is quoting £10 billion so any differences are either in the phasing by year or the source of the funding (taxpayer, land sales or some other new funding mechanism) rather than in the overall sum itself.
On revenue spending, while flat profiles (such as an extra £8 billion in cash a year) may look odd, on the evidence available to us, the Labour offer looks the most generous, certainly in the early years. However, as the years go by, the Liberal Democrats’ approach of adding the impact of additional pay rises and bursaries to the health settlement will erode this lead (unless Labour alters its profile of spending growth) and, of course, the long-term settlement they aim for may also change the assessment by the end of the parliament. As such, they could argue that they have both put forward a short-term plan and made clear they intend to follow this with a long-term plan. The Conservatives’ offer is perhaps the most straightforward, although questions should be asked about plans for non-protected spending and about the profile of the growth. Even so, as the Conservatives presumably do not plan to provide all the uplift early on in the parliament, Labour and the LibDems offer more in the early years and may also do so in the later years.
And for the next election, it would help everyone if comparing the offers from different parties did not require a spreadsheet. The proposals from Labour and the LibDems for an Office of Budget Responsibility-style organisation for health and care would go some way to providing the transparency that is needed.
1 June 2017, 10:16 am
Gone are the days when mental health was a niche public concern. Over the past few years there have been many advocates for ‘parity of esteem’ – a commitment to putting support for mental health on a par with support for physical health. That mental health is prominent in each of the Conservative, Labour and Liberal Democrat manifestos is a testament to these voices, and reflects a shift in public opinion that considers equitable treatment of mental ill health as a key policy agenda.
Current NHS strategy is outlined in The five year forward view for mental health, an action plan for improving mental health outcomes by 2020/21. Components of that plan are evident in all three manifestos – for example, all three make commitments to ending out-of-area placements although with slightly different emphases – but are most prominent in the manifestos of the Conservative and Liberal Democrat parties, perhaps reflecting the roles of the coalition and current government as architects of the service developments currently under way.
This reflection of the plan is welcome as there is a general consensus that, if implemented effectively, many of these developments have the potential to deliver measurable improvements in access to timely and effective treatment for mental ill health.
This takes us on to what the parties propose to do in addition to, and beyond, the life of the current plan. It is here that the parties diverge. Theresa May’s personal commitment to mental health is clear from her time at the Home Office where she oversaw a drive to reduce the use of police custody as a ‘place of safety’ for people experiencing a mental health crisis and her first speech as Prime Minister which focused on mental health as a ‘burning injustice’. The Conservative manifesto continues this narrative, but it is the proposal to use legislation to enact change that is most notable. The proposed replacement of the Mental Health Act 2007 presents opportunities to start afresh and address legislation which still reflects the original 1959 Act, passed at a time when most people with mental health problems were housed in asylums. However, what this aims to achieve remains unclear and it is hard to forget that previous attempts to introduce a Mental Health Bill in 2006 had to be abandoned because of a lack of consensus on what changes in legislation could effectively achieve and on the balance between state intervention and individual rights.
The Liberal Democrat manifesto reinforces their commitment to using access standards as a means of driving improvement – an approach instigated by the coalition government – with the introduction of a new standard in A&E. However, there is also evidence of the approach adopted by the West Midlands Mental Health Commission, chaired by Norman Lamb which prioritises implementation of service improvements where there is a good evidence of impact, and development of longer-term solutions in areas of identified need. The Liberal Democrat manifesto commits to the roll-out of two evidence-based models of support for people with mental ill health, Individual Placement and Support in employment services and Liaison and Diversion in criminal justice settings, while developing work around supporting good practice among employers and a campaign to improve mental resilience.
Labour’s commitments focus on mental health in children and young people. This includes a commitment to increasing the proportion of the mental health budget spend on support for children and young people, funding for schools-based counselling, and the introduction of a mental health indicator for children. There is also a pledge to work towards ‘a new model of community care’ that brings together mental health with primary care and social care, although the manifesto puts little flesh on the bones of this commitment.
Having a plan is the first step, but if there’s a ‘burning issue’ in mental health, it’s funding. All three parties have tackled this, but in different ways. Both the Liberal Democrats and Labour have opted for ring-fenced funding for mental health, but where the ring-fence is applied varies. The Liberal Democrats plan to raise an additional £6 billion of funding for the NHS from which £1 billion will be ring-fenced for investment in mental health. In contrast, the Labour commitment is to ring-fence ‘mental health budgets’ to ensure allocated funding reaches the front line. Experience suggests this may prove challenging and risks placing undue restrictions on what is funded and how, particularly given the breadth of mental health commissioning and the move towards greater integration. The Conservative manifesto reiterates their commitment to delivering the funding increases set out in the Mental Health Forward View. It is assumed that new manifesto commitments will be met through the £8 billion increase in NHS spending pledged by the end of the parliament, but the challenge of getting funding to the front line where it is most needed remains.
Each party offers a different plan for delivering improvements and different ways of funding it, but we can be sure that whichever government is in place after 8 June, mental health will be part of the policy agenda. Yet while we remain long way from the reality of ‘parity of esteem’, one thing that government can be certain of is that the pressure to deliver improvement in mental health will be ever present.
24 May 2017, 4:42 pm
There is more that unites the Conservative, Labour and Liberal Democrat manifestos on the NHS than divides them. All three parties reiterate their commitment to the enduring principles of the NHS. All promise to increase NHS funding during the next parliament. And all outline plans to improve care and to deliver key waiting time and other standards.
Where they exist, the differences between the three parties relate to the extent of these commitments, how they will be paid for, and which other issues each party sees to be important. On funding, for example, there are small but not trivial differences in the scale of increases planned, although comparisons are not helped by lack of detail on the commitments that have been made. From what we know, it appears that Labour’s plans are marginally more generous than those of the Conservatives and Liberal Democrats – at least in the early years of the parliament.
Labour and the Liberal Democrats plan to fund spending increases by raising more from taxes – on people earning over £80,000 a year in the case of Labour and by putting 1p on income tax in the case of the Liberal Democrats. The Conservatives plan to means test winter fuel payments and use the savings to increase spending on health and social care. Even with these commitments, spending under any future government will rise by only around 1 per cent per annum in real terms, well below the long-term annual trend of 4 per cent and less than the Office for Budget Responsibility has indicated is likely to be required.
Issues seen to be important to each party include giving priority to children’s health (Labour), exploring the possibility of a dedicated health and care tax (Liberal Democrats), and reviewing the operation of the NHS internal market (Conservatives). The Conservatives also plan to introduce legislation to create an independent health care safety investigations body, Labour makes a commitment to legislate on safe staffing levels, and the Liberal Democrats promise to establish an independent monitoring agency for health and social care, similar to the OBR.
The absence of any really radical plans for the NHS, in contrast to some of the proposals put forward for social care, has the benefit of creating a degree of certainty for NHS leaders. Readers of Labour’s commitment to repeal the Health and Social Care Act and reinstate the powers of the Health Secretary to have overall responsibility for the NHS might disagree with this assessment, but in truth the powers of the Health Secretary have never disappeared. Repealing the Act could also end up looking similar to the Conservatives’ commitment to consult on and if necessary make legislative changes to support delivery of NHS England’s plan.
Yet with certainty also comes anxiety. The prospect of five more years of austerity when the NHS is struggling to deliver current standards of care represents a huge challenge, and this will be accentuated by the risks associated with Brexit, especially in relation to retaining and recruiting EU staff, despite manifesto commitments to safeguard the rights of EU nationals working in the NHS. The absence of detail behind spending commitments will also raise concerns about the impact on budgets for public health and for education and training and the effect of social care pressures on the NHS.
What is clear is that the NHS must use new resources to support reform and not just to prop up existing services. This means taking forward work that has started on sustainability and transformation plans – assuming that these are allowed to continue – and developing further the new care models that seek to achieve greater integration of care. The NHS five year forward view will now extend over eight years, creating more time – though no less urgency – to make the transformations of care required to meet the changing needs of the population. The spotlight will be on NHS leaders to demonstrate that the Forward View really can deliver transformation.
In some areas, changes will be needed to the provision of hospital services, for example by concentrating some services in fewer hospitals where there is evidence that this will improve outcomes for patients. Shortages of doctors, nurses and other frontline staff are making these changes more urgent because of the difficulty many hospitals are having in sustaining safe services. Where the clinical case for change has been made, politicians should not stand in the way of this, even in the face of public concern and the likelihood that some patients will need to travel further to access care.
The NHS must also make evolutionary and rapid organisational changes to tackle the complex and fragmented legacy of the Health and Social Care Act 2012. The most promising possibilities lie in the emergence of accountable care systems, in which providers collaborate to meet the needs of defined populations. If these systems are to succeed, the work of national regulators needs to be aligned and streamlined to enable leaders to build accountable care systems appropriate to their areas. Changes to the legal framework, as foreshadowed in the manifestos, could also help, provided that they do not herald a further damaging and distracting top-down reorganisation.