An NHS true to its founding values
Two months ago, Labour’s conference took a historic decision; one which allows us to put people at the centre of the health and care system in a way that was never achievable before.
By endorsing full integration of health and social care, Labour has opened up an enticing possibility: a single service for the whole person, meeting all of their needs – physical, mental and social.
That simple change alone creates the conditions for the true personalisation of care in the 21st century. Labour should now set this as the central goal of ‘whole person care’.
By bringing social care together with the NHS, we can start where people and their families want to be – in their own homes – and build out from there. This is a big change from the 20th century when we thought of health in terms of buildings and institutions. In the 21st century, the home and not the hospital should be the default setting for care. Wherever possible, people should be supported by a single team providing high-quality, personalised care with the aim of helping them get the most out of life. It will finally make a preventative service a reality.
Of course, this is some way from where we are today. England has a fragmented health and care system, where physical, mental and social needs are met through separate, disjointed services. This disempowers people and is wasteful of resources.
People’s common experience is of a series of disconnected encounters with professionals and the frustration of telling the same story to every person who comes through the door. As no one is accountable for the totality of one person’s care, people fall between the gaps and true accountability is hard to achieve. This feature of our current system holds as true for vulnerable children and adults with disabilities as it does for frail, older people.
A single service for the whole person opens up the possibility of a simple, but revolutionary, answer to this common problem: a single named contact for the co-ordination of all care needs. This modest step would probably do more to empower people – and carers in particular – than anything else in this area. At a stroke, it would make services much more accountable. It is also one easy way to explain the difference that ‘whole person care’ could make on the doorstep: for the increasing number of people in their 40s, 50s or 60s who live away from their parents and face the anxiety of making multiple phone calls to arrange their care, it will make a great deal of sense.
If our vision of a personalised NHS is to be sustainable in the 21st century, it will mean that the state has to start thinking very differently about informal care and what it does to support it. For too long, carers have been invisible to the system. They are left to plug the gaps between the random, unconnected encounters with professionals. Often, far too much is left to them meaning that, for some, the caring burden is too great. This can’t go on. Assessing and supporting carers’ needs must be hard-wired into ‘whole person care’.
So how do we move the system decisively in the direction we want?
In the past, our approach has been to make change through setting targets. That was when the big challenge was reducing waiting lists. Now, we face a different kind of challenge: improving the care of vulnerable people with multiple needs.
Targets will continue to have a place in ensuring timely care for people accessing services in an episodic fashion as and when the need arises. But central to Labour’s new mission should be to improve dramatically the way we care for older people. If that is the case, we must recognise that a top-down, target-driven approach will not deliver the personalised care we want.
So, rather than targets, which drive accountability from above and often lead to people looking up to managers, we need to look at powerful rights for individuals to pull the system in the other direction: towards a person-centred service, with more options for care in the home; with carers supported not ignored; and with equal value placed on mental and physical health. One of the great benefits of this approach is that it will also help staff to do what they want to do, which is to focus on the person in front of them and all of their needs in a way that our current model of delivering care doesn’t allow.
Already, the NHS constitution affords people some limited rights on waiting times and Nice-approved treatment. Various ideas have been suggested for how it could be updated to pull services towards whole person care, for example:
- Right to a single named contact for the co-ordination of all care (physical, mental and social)
- Right to an individual, integrated care plan agreed jointly between individuals, their families and professionals
- Right for your carers to receive an assessment of their needs and to have respite care
- Right to receive treatment in the home where it is clinically safe to do so (such as the right to give birth at home or to end life at home)
- For people with a range of complex needs, the right to social and mental support in physical health settings (for instance, if mum or dad has to go into hospital, a known care worker could go with them to provide help on the hospital ward)
- Right to counselling and therapy as an alternative to medication
As this stage, these are just examples to get the debate going rather than firm proposals. But they begin to illustrate the kind of changes that ‘whole person care’ could make possible and what that might look and feel like to the public. And it also gets Labour’s focus where it needs to be – on services not structures. In health, there is always a tendency for any policy debate to become mired in the minutiae of organisational restructuring. That was Andrew Lansley’s mistake and we won’t repeat it.
We must maintain a laser-like focus on what ‘whole person care’ will mean for people and how it will change their experience of care. That is the clear task we have set Sir John Oldham and his commission on ‘whole person care’ which will report early in the new year. We don’t need new organisations; we simply need them to work together in a new way.
People will rightly question whether a system offering this degree of personalisation can be afforded. My response is that it is the status quo which can no longer be afforded.
Today’s silo-based approach to the provision of public services is a luxury we can no longer sustain. Such is the medium term outlook for public spending that all professionals will need to open their minds to working differently and with fewer organisational boundaries. The simple premise behind ‘whole person care’, and full personalisation, is that the more we give people the support they are asking for – when and where they need it – the more likely it is to work and, therefore, be better value for money. It is providing care in an uncoordinated way that is so wasteful of public resources and is leaving increasing numbers of elderly people trapped in expensive hospital beds.
So this is why it is right to place personalisation, meaningful choice and control at the heart of Labour’s vision for a 21st century health and care service. But this brings me to a point of contrast with the prevailing thinking of the last decade. Too often, there has been an unspoken presumption that only a market-based approach can offer true ‘reform’ of public services. I think the opposite is true. In a century when care is much more complex, and is about helping people with multiple needs, it is clear to me that we can give people more advanced notions of personal control in an integrated, collaborative system than can ever be on offer in a highly-fragmented, competitive market.
Similarly, ‘choice’ has too often been used to refer simply to choice between competing providers of the same service, rather than more substantive choices such as where and how services are delivered – like the option to receive treatment at home.
Giving people that most fundamental choice of all – the chance to choose where to end life – requires organisations of scale able to coordinate hospital backup should it be needed. This approach makes it much easier to build a sense of one team around the person. By contrast, the logical consequence of this government’s market framework is the fragmentation of services, with an ever-increasing number of providers on the pitch competing for different elements of a person’s care, increasing its cost and complexity and limiting the degree of control people have.
It is true that Labour’s approach may lead to NHS organisations operating on a wider footprint – from home to hospital, covering the full spectrum of care (physical, mental and social). But that is precisely why we must balance that by giving people meaningful rights to get the personalised care they need.
The biggest barrier standing in the way of Labour’s vision of a public, integrated health and care service is, of course, the 2012 Health and Social Care Act. Even the chief executive of the NHS has now admitted that the act is a barrier to integration and has left the NHS ‘bogged down in a morass of competition law’.
People who have not followed the detail of the NHS debate since the election may find this an incredible statement. With minimal media scrutiny, the current prime minister, who in opposition promised to protect the NHS, has managed to do something that Margaret Thatcher never dared try. Just when the future demands integration, he has placed the NHS on a path towards fragmentation and privatisation.
Part of Labour’s task between now and the 2015 election is to ensure that ‘no top-down reorganisation of the NHS’ becomes to Cameron what ‘no rise in tuition fees’ is to Clegg. But, of course, we must do more than that. We must frame the big choice before the country.
That’s because the NHS is approaching a fork in the road. It either continues to embrace marketisation and fragmentation, with all the threats that entails, or it goes in the opposite direction and becomes more collaborative and integrated, so it can meet the challenges of the 21st century. The next election will decide which path it takes, and the decision will have irreversible consequences.
The choice on the NHS at the 2015 election is coming into focus: Labour for a public, personalised NHS true to its founding values; Conservative for a market-based approach to health and care. I think I know whose side the public will be on.
Andy Burnham MP is shadow secretary of state for health
Andrew Lansley, Andy Burnham, NHS, NHS reform, whole person care