Liberating the NHS – some thoughts

There has a lot been written since Lansley announced the new government White Paper on reforms to the NHS called ‘Equity and Excellence : Liberating the NHS’ My hesitation in summarising the points immediately came partly because the thought of another ‘transformational change’ was just about grinding my brain into smithereens. I don’t have enough digits to count the transformations and reconfigurations that have been planned and actioned over the last 10 years of my practice. I haven’t actually read the White Paper – work has been tiring! I have read a few summaries though so that will have to suffice as far as analysis goes until I find some more hours to plug into a day!

In very brief summary, there is talk of GPs taking over the commissioning of care and services in consortia and the abolition of PCTs. Hospitals will be forced to become Foundation Trusts and these Foundation Trusts would be able to lift the limits they currently have on provisions for private patients.

There will be an independent NHS Commissioning Board which will oversee the processes and public health functions will be handed back to the already overstretched (remember the council tax freeze!) local authorities.

More responsibility for the integration of health and social care services will fall back to local authorities and the Financial Times quotes Lansley as claiming that some of the expertise for commissioning mental health services might exist within local authorities saying

There were “sufficient synergies” between mental health and social care for councils to provide “very good support” for mental health commissioning, he said.

The problem is that we can very well assume that there will be little ring-fencing of local authorities already over-stretched budgets. Cuts are coming hard and fast. Supposedly the NHS and health budgets were protected. Local authority budgets are fair game.

Rethink and MIND have both issued statements raising concerns about the expertise that might exist in primary care to commission mental health services.

With Rethink’s press release explaining that

Rethink discovered that only 31% of GPs feel equipped to take on the role for mental health. While three quarters of GPs say they can take responsibility for diabetes and asthma services, less than a third felt the same for mental health services.

Rethink is concerned that unless there’s a national plan to up-skill GPs in mental health many of the 1.5 million people with severe mental illnesses may fail to get the treatment they need.

Meanwhile, Paul Farmer, the Chief Executive of MIND issued a statement saying,

“Transferring powers for commissioning to GPs presents an opportunity for them to develop mental health services that meet local needs and give patients the choice they want.

“However, GPs currently lack the specialist mental health knowledge and training to understand the complexities of mental health commissioning.

“There are already huge variations in the standard and types of mental health care patients receive depending on where they live. For example, access to talking therapies remains patchy, with people waiting months and sometimes years for certain treatments while antidepressant prescribing has soared. Any structural changes must not widen inequalities.

“GPs already have a heavy workload and asking them to add commissioning mental health treatments on to their to do lists will be an extra burden.

“It’s crucial that these new responsibilities don’t cut the amount of time they spend talking to patients.”

I wonder if it will be a case of those who are able to ‘shout loudest’ for their services will be the first to benefit from ‘choice’.

While supposedly this choice will be market-driven, it’s worth looking at the past experience of the  implementation of the ‘care management’ model of social care which was supposed to add purchasing power to social workers and institute a purchaser/provider split between the local authorities and a more extensive range of providers. What the free market managed to do in these circumstances was absolutely gravitate to far fewer choices by larger private companies who were able to drive costs down by employing temporary staff on minimum wages to provide personal care services.

Putting the budgets in the hands of social services teams led to the extension of ‘procurement teams’ who took bids from the private companies and forced the prices (and quality of care, incidently) lower and lower.

Unsurprisingly, these changes make me nervous. Not just because change is so very tiring but it is also costly in terms of consultancy fees.

Dan Parton in the Social Care Blog excellently summarises some of the implications for social care in general and basically finds that there is a span from very little to absolutely nothing mentioned about people with learning disabilities, mental health problems and dementia in the White Paper.

He ventures a guess that possibly these services will be mentioned separately at a later date but it is a very tentative hope. The problem is that the people who use these services are not the ones that the Health Secretary is likely to be thinking will be clamouring to support him.

The Shrink at Lake Cocytus also summarises his response. Again, there is the sense of reconfiguration fatigue that I can absolutely and completely recognise in my own reaction. He extends his fears that the commissioning processes which can be enormously complicated and time consuming will be picked up by large multinational companies who will happily – at a fee – do this job.

The other element packed into the White Paper and mentioned by Community Care is that NICE (National Institute of Clinical Excellence) will be given more powers to ‘drive improvement in social care’. This of course begs the massive question about the position of the current ‘Social Care Institute of Excellence’ and whether will be still actually exist or be consumed by NICE. While SCIE has charitable status and therefore has some independence from the government, if all it’s functions are taken over by NICE – and NICE having further statutory functions – it makes one wonder what might be left of the more distinctive SCIE and whether it is a sign of things to come where social care is marginalised further.

Indeed, SCIE’s response to the White Paper seems a little defensive and nervous

With regard to our future role, as care services minister Paul Burstow has made clear “SCIE … continue to have a role but it won’t be the same role they played directly alongside NICE in the past”. SCIE provides a wide range of services – including supporting the development of quality standards alongside NICE.  As an independent charity we explore innovative approaches to deep-rooted challenges (eg our new approach to serious case reviews in children’s safeguarding). We provide practical, accessible, evidence-based support to frontline care workers through our guides and learning materials, including digital solutions such as Social Care TV. Crucially, we capture and analyse information about latest developments in social care – and share that quickly with the sector (eg our updated guide to personalisation captures the latest developments in how to transform adult care services).

We will work closely with Department of Health and social care organisations to ensure that the personal care and support – as well as the health care – needs of individuals are supported by the reforms within the White Paper. We have the contacts and knowledge needed to ensure this happens.

There is a sense of ‘look, look, we ARE useful – we ARE doing good things’. I think it would be a shame as personally, I’ve found SCIE information very useful.

Indeed, David Brindle, in the Guardian expresses some of these concerns in a piece earlier in the week. , in a piece frighteningly titled ‘Is social care about to be swallowed up by health?’. It’s a look ahead at some of the possibilities that may lie ahead for the social care sector and it doesn’t look rosy.

I can’t say that the investigating some of the details of the White Paper has left me with anything except trepidation and a wish to fight and challenge some of the implications that haven’t been expanded upon yet.  I see it as absolutely crucial that the needs of those with social care needs are not forgotten or left behind through this process.

Interesting times.

Cutting the Fat

Yes, it’s Budget Day today but I felt the analysis is better suited to a discussion after the announcements have been made rather than trying to second-guess them although we can say without any doubt that cuts are the order of the day.

On the barest of connections (cutting excesses – yes, I know it’s a VERY tenuous link!), I was interested in this story in the Guardian today , which reports on a study from NICE (National Institute of Clinical Excellence) which attacks the food industry for some of the contents of processed foods and how it affects general health of the population as well as suggesting some actions that should be taken.

The suggestions included banning trans-fats, bringing in tighter controls on fast food outlets which are placed close to school and ensuring that lower fat, lower salt are cheaper than unhealthier options.

The government is quoted as saying that it is an individual decision as to food consumption which is a fair point however the choices are very often stifled by cost. It is cheaper to eat processed foods. Not everyone has the same opportunity of access to some of the cheaper supermarkets and suppliers. As long as the programme of rolling out free school meals has been stalled, there is a public health issue regarding the types of foods that are available.

Public policy seems, in my mind, to have always been doing pretty badly on preventative work, possibly because there are less tangible measurable ‘targets’ to achieve by someone not getting diabetes in the first place or never taking up smoking or not falling because they were provided with strong support or not accessing mental health services because lower level supports were available.

I’m not necessarily ‘anti-targets’ but  having worked within systems where targets are paramount and linked extrinsically to funding, some are positively ridiculous and not even remotely connected to standards and levels of care.

The obsession with targets though has added extra layers of bureaucracy and certainly in social work, which, to be frank, is the area in which my knowledge base generally lies, has taken away some professional competency and expertise away from the day to day job in the interests of meeting, sometimes spurious targets.

But back to the NICE report – it makes sense. It’s something that has been known in public health circles for a while but processed is cheaper and that’s the real issue that needs to be tackled. If the government are happy to tax alcohol and cigarettes on the basis of the more general costs attached to providing healthcare for those who choose in this way, then why not subsidise and promote healthy food choices and tax higher fat foods…

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As they say, food for thought.