Those hoping for insight at conference into Labour’s future health policy were left clear about the party’s animosity to the Health and Social Care Act but none the wiser about what would animate it in government.
Will Labour find a moral purpose on health as it seems likely to do on social care? The party must avoid complacency about its record in government. For although huge progress was achieved on waiting times and some outcomes, such as stroke and cancer, there was a great deal still to do.
Consider these facts:
100 people a week lose a toe, foot or lower limb due to diabetes.
Our death rate from asthma is over five times as high as in countries like the Netherlands.
25,700 older people failed to survive the winter in 2011, considerably more than in colder neighbouring countries.
These figures are not improving. Yet all of them are preventable. And they summarise the challenge facing us. It is not to do with the performance of hospitals, which has held up despite the financial constraints. It is to do with the management of chronic and long-term conditions, which is now the main burden of disease we face.
What’s more, that burden falls excessively on the poorest communities, especially those in cities and in London, the north and the Midlands. And it’s not all to do with the long-term social determinants of health (a cause Labour must not abandon). Some of it is caused by lower expectations – poorer people often put up with worse symptoms or fail to ask for help soon enough. And some of it is the result of ineffective health services, which in places are failing to meet people’s needs. These outcomes are what health professionals call ‘amenable to healthcare’ – in other words, the health service can do something about. Those of us in the charity world would call it a scandal.
Yet the simple fact is that neither today’s general practice nor our acute hospitals are well suited to the task. That’s why there has been such a focus on changing the nature of community healthcare – something that most health managers regard as a much bigger issue than the structure of commissioning.
There are excellent examples of new preventative healthcare delivering results for patients at risk in the community. Some of these are run by foundation trusts, some by GPs, some by charities and a few by the private sector. Patients don’t seem to mind who. But mostly these are small-scale services that need to be scaled up quickly. They are not mainstream provision of any current NHS trust.
The fundamental challenge in health is to create new forms of provision that stop long-term conditions becoming acute. I want to hear about how Labour will make this happen, especially in the poorest areas in some of which general practice has traditionally been smaller and weaker. Yet the focus remains on structure, not purpose, who runs services, not what services are needed to improve outcomes.
There are good grounds for arguing that Labour should accelerate rather than abandon its reformist policies, so it is disappointing now that the puff has gone out of the party’s sails.
Although most commentators were dismayed by the current reorganisation, the prospect of yet another restructuring of commissioning from a future Labour government has been the subject of some black humour. The UK is already the butt of jokes in most other countries at the frequency with which we reorganise commissioning and our systematic failure to allow any reform the time to work. Surely Labour won’t allow this merry-go-round to continue? Well, I thought the same of Andrew Lansley in 2009.
Leaving aside the reorganisation, there is much about the new health landscape that is recognisable as former Labour policy.
‘Contestability’ was meant to ensure that patients got the best standards of care by opening up poor services to alternative providers. Done well, on the basis of integrated models of care, this is managed competition, not a free market. In community health it is being done to fast-track the development of services which largely don’t yet exist.
Clinical commissioning groups also have the hallmarks of successful Labour initiatives like foundation trusts and academies. The best are run by experienced clinicians with strong boards, deep roots in the community and a passion to improve outcomes and challenge poor standards. Labour could strengthen their hand by ensuring performance data is published, inspection is improved, governance is robust and struggling CCGs are performance-managed.
Labour seems at a crossroads, either towards or away from reform. The choice should reflect the core agenda that the party is pursuing: Is the fundamental goal that the state should be provider of health services? Or is it that aspirations to a good health should be delivered fairly and effectively no matter where in the country you live?
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Neil Churchill is the chief executive of Asthma UK. This article is written in a personal capacity
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“25,700 older people failed to survive the winter in 2011”
*cough* Housing Stock. Why don’t you read up the work of Gabriel Scally one of the country’s foremost public health doctors? He points out that the highest proportion of people who die in winter is in Portugal, for the simple reason that their houses are not built to withstand cold weather. Not healthcare. We have very poor housing stock, much of it due to Thatcher’s privatisation of council housing, making right-to-buy householders responsible for making their houses insulated and energy efficient (which, of course, they failed to do).
“100 people a week lose a toe, foot or lower limb due to diabetes.”
The problem here is from Type 2 diabetes. This is yet another public health issue because a large proportion of people get type 2 diabetes from obesity. We need policies of moving away from cars to walking and cycle use, and moving away from our calorie rich cheap food policy to one which is healthier.
So basically two of your examples have very little to do with primary or acute care.
“There are good grounds for arguing that Labour should accelerate rather than abandon its reformist policies, so it is disappointing now that the puff has gone out of the party’s sails.”
This statement shows that you fundamentally misunderstand the proposals presented by Andy Burnham. Integrating acute, mental and social care is a radical proposal. Making local authorities the “lead commissioner” of the integrated system is even more radical. I am sure that you are aware that local authorities are responsible for transport and housing? (And hopefully if Gove’s centralising policies are reversed, for education too.) There is a once in a generation possibility to get public health high on the priority list.
“Done well, on the basis of integrated models of care, this is managed competition, not a free market”
Well, the Netherlands tried “managed competition” in their healthcare and it has been shown to have produced a more expensive system with no more patient choice. In terms of the NHS patients are not able to exert choice like they do with, say, purchasing a TV. Patients will never be informed enough to do this. As you have said yourself “patients don’t seem to mind who”, not “patients CHOOSE from a diverse range of providers”. Patients largely choose what they are offered. “Contestability” is commissioner choice (as is AQP) and not patient choice. By definition, if you increase the numbers of providers you increase capacity and reduce the ability to plan. That results in over capacity and an inefficient system. We are part way through a decade of austerity, now is not the time to introduce such inefficiencies.