18 January 2008
Prevention is the government's big idea for the NHS in 2008, with an ambitious screening programme, personal health and social care budgets and a push against obesity and binge-drinking. Noel Plumridge reports
If you want a job done properly, the old adage goes, do it yourself. It's many years since we expected to call in time-served tradespeople to undertake basic domestic maintenance tasks: rising costs and skills shortages have encouraged most of us to learn the fundamentals of plumbing, roofing, plastering and decorating. No one likes to be helpless. When a pipe bursts in the middle of the night, it's sensible at least to know where the stopcock is, and how to turn it.
Traditionally, however, we've been encouraged to leave health care to the experts. Not for nothing are people undergoing medical care known as 'patients'. But Prime Minister Gordon Brown and Health Secretary Alan Johnson intend to change all that. The NHS of the passive patient is to disappear.
'People are telling us that they want a life not a service,' says Johnson, who is considering introducing individual, personally controlled budgets for some elements of health care.
And Brown's January 7 speech at King's College, London, set out a vision for the NHS 'of patient power, patients engaged and taking greater control over their own health and their health care too'.
A first move will be the introduction of a screening programme for early detection of abdominal aortic aneurysm in men over 65. Brown says this could save up to 1,600 lives a year. A national screening programme for other life-threatening diseases – cardiovascular disease, stroke, diabetes and kidney failure among them – will follow. Blood tests, electrocardiograms and ultrasounds are to be available 'when you want and need them' in GP surgeries.
The Brown vision covers chronic disease management as well as screening. It envisages a more personal service, 'one that intervenes earlier, with more information and control put more quickly into the hands of patient and clinician'. Later this year, the government will publish a prospectus defining how people in England with long-term illness, all 15 million of them, will get a choice of options covering care at home as well as being an 'active patient'.
Brown's vision of 'engaged' patients is a direct reference to Sir Derek Wanless's 2002 review of health funding and last September's progress report. The review outlined three scenarios for future health care provision, described as 'slow uptake', 'solid progress' and 'fully engaged'.
The 'fully engaged' scenario assumed significant gains in efficiency and productivity, but also major improvements in public health and much better general levels of fitness. This allowed it to become the cheapest of the three scenarios, albeit still with a real growth in resources of 126% between 2002/03 and 2022/23.
Brown emphasises giving 'all of those with long-term or chronic conditions… a far more active role in managing their own conditions'.
But this new stress on self-reliance and taking responsibility for one's own health and welfare is not unique to the NHS. Putting people first: a shared vision and commitment to the transformation of adult social care, published in early December, is a protocol agreed by various government departments and representatives of local government, the NHS and social care organisations.
Anne Williams, president of the Association of Directors of Adult Social Services and one of the signatories, describes it as a 'landmark concordat'. But it has something of the feel of a diplomatic treaty, signed by no fewer than 19 individuals – including five secretaries of state – and couched in language that suggests each sentence has been carefully negotiated.
Often in such documents one finds little more than the lowest common denominator of policy aspiration, but Putting people first might prove to be the first serious attempt to turn the government's 'personalisation' agenda into a practical reality, as well as a step on the road to the review of social care funding announced in the 2007 Comprehensive Spending Review. And real money accompanies the words: £520m is to be allocated to councils, over three years, in the form of a ring-fenced social care reform grant.
Perhaps the most far-reaching proposal is for a personal budget for anyone eligible for publicly funded adult social care support, except for emergency care. Older people or their chosen relatives, for example, will have the option of having money paid directly into their bank accounts by councils, so they can purchase their own packages of care. Thirteen local authorities are already running pilot projects, and Putting people first suggests that the approach will now be spread more widely.
One of the 13 is West Sussex County Council, where Chris Moon-Willems, who works in the council's adult services team, has been taking part in the pilot programme as a relative. Moon-Willems' parents now receive £7,000 a year for their personal care, which she manages on their behalf. She says the change to individual budgets 'isn't about giving people a menu of options, it's about changing the menu so that it can be adapted for a person's individual needs.
'Leaving decisions about what is best for a person to those who know and love them can often achieve better value for money… relatively small amounts of money can be stretched further because people come up with creative solutions that a professional wouldn't necessarily think of.'
Local authorities will be leading the creation of the new and more responsive arrangements for adult social care outlined in the protocol. Anne Williams expresses Adass's 'delight' that it 'recognises the key role that those responsible for delivering social care have in fulfilling the country's expectations'.
And Local Government Association chair Sir Simon Milton, another signatory, approves of the additional funding. 'The new grant for social work reform will go some way to enable councils to move towards a more personalised and preventative system of care,' he says.
At first glance, Putting people first might be read as an extension of consumerist values to state-funded social care, coupled with a limited financial gesture towards critics of a CSR settlement that continued to give health a much larger share of funding growth than local government. The value of the new grant in 2008/09 is, after all, a mere £85m: not that much, given that the 2008/09 finance settlement offers local government an overall real-terms increase of just 0.9%.
But the protocol suggests that, in line with health minister Lord (Ara) Darzi's interim report on the future of NHS provision, personal budgets for people with long-term health conditions could well include health service resources. And Gordon Brown's statement supporting Putting people first made it clear that the proposals would 'allow all those who could benefit from a personal budget to receive one'; implying an ambition to extend the boundaries of NHS Patient Choice well beyond selecting which hospital to go to for an operation, and perhaps also a degree of strategic rebalancing between health and local authority spheres of accountability.
Some commentators suggest that after five years of tumultuous change, the NHS in England is now heading for a period of relative stability, bolstered by its recovery from a financial deficit of £0.5bn in 2005/06 to a forecast surplus of £1.8bn in 2007/08. Brown, the theory goes, is deliberately diverting attention elsewhere, and allowed higher-than-expected growth in the CSR settlement, to give the NHS breathing space and a rest from restructuring.
Actually, this seems unlikely. In reality, each of the major policy initiatives that have dominated the English NHS in recent years – payment by results, the Private Finance Initiative, practice-based commissioning, the role of the private sector and the autonomy of foundation trusts – is, to a greater or lesser extent, under evaluation. And the government is also obliged to address at least three significant strategic issues that might otherwise return to haunt both it and the NHS.
One is the state of public health, which returns us neatly to Wanless's September 2007 report. He praised the increases in funding since 2002, which have brought total UK health spending close to average European Union spending as a share of gross domestic product. He was, however, critical of the productivity that the NHS has achieved in return for the extra funding.
But with little appetite for further increases in tax-generated funding, and only so much scope for efficiency gains within the hospital sector, the Treasury will expect measures to make Wanless's 'fully engaged' scenario more of a reality. And this in turn implies focusing less on hospital throughput and more on effective primary care.
Hence, in part, the post-Christmas proliferation of media stories about obesity, binge drinking and associated social ills. For, in policy terms, there is a happy overlap between the Brownite social mantra of 'rights and responsibilities' and the reality of improved clinical outcomes where patients are more fully involved in determining their own courses of treatment. Behind the high-profile creation of a new generation of 'modern matrons' who 'case manage' frequent users of hospitals, there have been numerous quiet success stories from initiatives such as exercise on prescription and the 'expert patient' programme.
Sceptics, however, find in the language of personal responsibility applied to obesity and addiction a more comfortable alternative to tackling powerful interests in the alcohol and fast food industries. But Brown has promised to review the current complex rules for labelling the sugar and salt content of packaged foods. And while 'exercise on prescription' might win the backing of the disciplinarian tendency in the Cabinet, genuine success has been more common when that exercise includes a social component. Overweight 50-somethings often find gyms, populated by sweaty rugby players and leotard-clad aerobic stars, every bit as intimidating as their dietary regimes. Line dancing groups, walking clubs and the like might not provide the easy political sound bites but have a stronger track record of sustained success.
A second issue is the public perception of the NHS as bureaucratic and inflexible. The government's consumerist leanings have become increasingly frustrated in the health sector. Health professionals, and the medical profession in particular, have been relentless critics not just of the centrally imposed 'choose and book' software – used in GP practices to allow patients to select where they will receive treatment – but also of the underlying philosophy of choice. Despite the popularity of choice pilots in London and the West Midlands, many clinicians hold tightly to a belief that patients are not interested in choice and only want good local care.
Meanwhile, in recent months, GPs have become a serious obstacle to the government's 'personalisation' plans, not least through the British Medical Association's forthright opposition to any extension of practice opening hours. And there has also been a small but significant stream of media coverage critical not of access to health care, nor of hospital cleanliness, but of something more insidious: a lack of the personal respect consumers nowadays expect from service providers.
Any political gain from the NHS's immense improvements, and the government's massive investment, might ironically be undermined by a perceived lack of responsiveness to its customers. The government has recently shown its willingness to intervene directly. Its Valuing people now consultation paper, which proposes transferring funding for people with learning difficulties from the NHS to local government, was at least partly prompted by a severely critical Healthcare Commission audit of the quality of NHS care.
A third and arguably related issue is the fragility of NHS commissioning. The Healthcare Commission's annual State of healthcare report, published last month, makes gloomy reading. It accuses many primary care trusts of a fundamental lack of understanding of local health needs, which renders their commissioning strategies irrelevant. The Department of Health is working hard to promote its World class commissioning initiative, also published in December; but has a Plan B in reserve, in its Framework for procuring external support for commissioners. This would put the private sector, and insurance companies in particular, firmly in the driving seat.
Even if commissioning standards improve radically, there is still the thorny issue of legitimacy: the 'democratic deficit' raised by health minister Ben Bradshaw last autumn. 'Primary care trusts that increasingly will be responsible for spending vast sums of money and commissioning services don't have any direct democratic accountability,' he said. 'If people in their local area don't like what their PCT is doing, it is quite difficult for them to make their voices heard and to make sure that changes are made.”
When Sir Simon Milton recently called for local authorities to have the power to appoint and dismiss NHS chief executives, the NHS Confederation was quick to challenge the idea. But a degree of direct personal control of NHS budgets might go some way towards legitimising the use of resources, especially in an environment where commercial organisations are more visible in steering PCTs' spending choices.
Can individual budgets work? Professionals still harbour a considerable degree of scepticism. The history of such initiatives shows at best patchy success. Even if the technical and accounting issues (including systems capability, security of funds, responsiveness and prevention of abuse) can be overcome, giving patients genuine power remains deeply counter-cultural. Not just among health professionals, but also for many patients.
There are also material shortcomings in the current provision of primary health care. Who, some are asking, will undertake the additional screening? Where are the GPs? The DoH finds itself in a dilemma, keen to peg back the pay of doctors in primary care yet deeply reliant on GP support for its initiatives. Brown's vision includes 'allowing foundation trusts the freedom to provide primary care services where this is in the interests of patients', a clear enough signal of government impatience.
And the British Medical Association might again prove to be a significant obstacle. Richard Vautrey, deputy chair of the BMA's GP committee, has been quick to observe: 'Last year they were talking about taking money from disease prevention', adding that 'We are very suspicious.'
Nor can one ignore the context of the expected green paper on social care funding and its root cause, the widely acknowledged 'demographic time bomb' facing health and social care across Europe. The recent King's Fund report on options for social care funding, Securing good care for older people, estimates that the costs of simply maintaining the current system would more than double by 2026.
An explicit government aim is to redefine the relative shares of resource that will pay for the costs of an ageing population: how much should be directly state-funded and how much should be clawed back from individuals.
In this context it might be tempting to see individual budgets as an indirect way of increasing the scale of private contributions, allowing those who are able to 'top up' the funding for care provision. But it will be all too easy for critics to present this as privatisation by the back door (if individuals choose commercially provided services, such as chiropody, over NHS-provided care), or as dismantling the right to free NHS care.
For the core dilemma remains: NHS care is free whereas social care is means tested. This realisation might explain why Gordon Brown's vision of the future is not, as yet, overburdened by firm commitments and pledges.
Noel Plumridge is a former NHS finance director and the author of CIPFA's Payment by results
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