2014 – The priorities for the NHS start close to home
If the NHS is the national religion in Britain, 2013 might have been the year which started to challenge the blind faith of its adherents. It’s certainly been a difficult time for the health service and one which has begun to see it begin to return to the centre stage of political debate.
The long awaited Francis Report has been the salient event of the year. It’s damning criticism of care at Mid Staffordshire Hospital has shaken the NHS to the core, perhaps, as much as anything, because, as well as criticising the management and culture of an NHS institution, it also pointed the finger at the role of clinical staff in the neglect of patients. Events at Morecambe Bay, Colchester and other hospitals have confirmed that the issues at Mid Staffordshire are not a one off and are indicative of a wider malaise in parts of the NHS.
2013 was also the year when, after the chronic distraction of the reorganisation to end all reorganisations, the new structures of the Health and Social Care Act took over. It’s probably too early to judge their impact although there are undoubtedly signs that some Clinical Commissioning Groups (CCGs) are prepared to take a more radical and fundamental approach to challenging historic problems with services. What is clear is that the new system is, by definition, more fragmented.
2013 has also seen the gradual building up of problems across the system as the impact of financial pressures both within the NHS but just as importantly outside in the NHS, in social care, housing and welfare are felt. Whether it is pressure on A&E and the fear of a catastrophic winter, the crisis in mental health acute care or the workload pressures on primary care, the system is beginning to creak. Behind the immediate financial challenges lies the spectre of the need for major changes in the nature of hospital provision in this country if we are to have a system for the future which is sustainable in terms of finance and quality. As we get closer to an election the political will to address this underlying problem becomes more remote and in 2013 there were marked examples in Lewisham and Leeds, to name but two, of political resistance to service change.
So as we move to the New Year how should the NHS respond to the challenges it faces?
For me, that’s got to start with shifting the debate away from hospitals into an effort to define and promote what good community care should look like. The community has to be where we start the discussion about healthcare, redefining hospital as the intervention necessary to manage specialist interventions or the most complex cases.
This is the model of care which is most appropriate to meet demand driven not by the infectious diseases which were the bread and butter of the NHS when it was founded in 1948 but the incidence of multiple long term conditions which define the NHS in 2014. We need policy and financial incentives to align in a way which shift resources and attention onto primary and community services. It cannot be right at a time when we crucially need the money we spend to go so much further for £3 out of £4 committed to the NHS on acute hospitals when better value and better outcomes could often be secured by funding earlier intervention in the community.
We need commissioners, at both national and local level, to create the right incentives for integrating services. This also needs to embrace social care as, in the community, the artificial division between health and social care is particularly meaningless. Furthermore the move to create genuinely 24 hour services should not start in hospital but rather in the community where the sense that services are not available when they are required can be one of the biggest reasons why patients default to emergency and urgent care.
Finally we need political rhetoric, media interest, professional kudos and the priorities of regulators to focus on good community care. For a long time we have created a mental picture of excellent healthcare based on the image of the shiny new hospitals full of doctors in white coast and nurses in uniforms. There is a need to change the story pretty quickly and start constructing a picture of health care which values care delivered in the community. In 2014 we should celebrate not those localities with biggest hospitals but those with the best infrastructure of community care.
Those of us working in mental health have been there before. We closed our hospitals and shifted care into the community. We didn’t get everything right and many of the challenges around delivering joined up care in the community apply to mental health as much as any other sector. However what we do know, all too painfully, in mental health is that the public cannot be expected to accept hospital closures if the alternatives in the community are not properly thought through or properly resourced.
It is clear to me that health care in this country will not sustainable in ten years’ time if we do not grasp this nettle. It will need real leadership from all corners of the system, in particular at a time of such great pressure on resources. Without that leadership, however, we will betray the NHS. Priorities in 2014 do indeed start close to home.