12 Mar, 14 | by BMJ
Labour’s independent commission on health policy has made some welcome recommendations on integrated care and system reform, but could create conflict between the NHS and local government.
The commission, led by respected GP Sir John Oldham, develops the idea of “whole person care” championed by shadow health secretary Andy Burnham, intended to bring together physical and mental healthcare with social care.
It calls for the Payment by Results system to be reformed to stop rewarding episodic care in hospitals, and advocates outcome based commissioning. This would typically be achieved through a prime contractor, where one organisation is responsible for the delivery and coordination of services to achieve specific outcomes.
On reconfiguring services it wants a “national conversation,” to be completed by 2016, on the future of health and social care. If this means ministers will provide clear political leadership for reforming services then it has the potential to give renewed impetus to service improvements while encouraging a more realistic debate about what the state can afford.
But when it comes to tough choices about hospitals, Labour’s frontbench gives every indication of avoiding difficult decisions and following public opinion rather than leading it. Rhetoric deployed in opposition may limit their room for manoeuvre in office.
Virtually the entire NHS will welcome the proposal to scrap the coalition’s competition laws—although aspects of the NHS such as autonomous and competing foundation trusts mean there will still be a role for the market. This report makes no mention of Burnham’s desire to make the NHS the “preferred provider” of services, instead of the “any qualified provider” approach.
It is clear from this report and Labour leader Ed Miliband’s recent Hugo Young lecture that Burnham’s big idea—moving NHS commissioning into local government—has been dumped. But in seeking both to strengthen democratic accountability for the NHS and encourage integration between health and social care, Oldham’s proposals create two potential areas of conflict between the NHS and local government.
First, Oldham proposes that the health and wellbeing boards overseen by councils would become the “system leaders” for integrated care, focusing on developing a coordinated commissioning plan for long term conditions, disabilities, and frailty.
Bringing health and social care together at the boards was always the intention, but specifically identifying them as system leaders would mean that a GP membership organisation—the clinical commissioning group—would be accountable to a body led by councillors.
Alongside this is a recommendation to strengthen provider representation on the boards. Taking all this together it is easy to imagine local hospitals feeling threatened by CCG plans to move care into the community lining up with councillors in opposition.
The idea of giving the boards a central role has many strengths, particularly in creating the potential for a single commissioning budget across health and social care, but making it work will be tough.
The second recommendation is giving NHS England—renamed Care England—overall responsibility for whole person care. While this sounds benign, it would entail giving the organisation influence over social care spending, local government’s biggest and most difficult budget. Local democratic decisions balancing out social care need against the huge diversity of competing demands which councils face do not lend themselves to central oversight, and local government would fiercely resist it.
Labour is attempting to overcome the separation of NHS and social care which has baffled and frustrated generations of service users. In doing so it is pursuing the care equivalent of nuclear fusion—trying to do something which offers limitless possibilities in theory but is always elusive in practice.
The reality is that the boundary between the two systems will always be messy and difficult. There is no politically deliverable structural change that can be devised in Whitehall which will avoid that.
Richard Vize is a journalist and communications consultant specialising in health and local government. He was the editor of the HSJ 2007-2010.