Shadow health minister Liz Kendall - speech to "The New NHS' Reform conference 12 February 2013
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It’s a week since Sir Robert Francis published his report on the failings at Mid Staffordshire Hospital.
And – let’s not forget – three months since the Government produced its final report into the scandal at Winterbourne View.
Whilst the appalling events at these hospitals do not represent what is happening in the wider NHS or social care, there are serious lessons that must be learnt from the bottom to the top of the system: for providers, commissioners, regulators, professional bodies – and yes, politicians too.
I don’t intend to go through all these today. Instead, I want to focus on two fundamental challenges, raised by both Mid Staffordshire and Winterbourne View, that must be kept at the forefront of our minds if we’re going to build a care service that’s fit for the future.
First, ensuring patients, users, families and the public are not just at the heart of services but in the driving seat of change.
At both Mid Staffordshire and Winterbourne View the needs, views, experiences and concerns of patients and their families were repeatedly ignored. People did speak out; there were warning signs; but these were not picked up, with tragic consequences as a result.
Second, how we radically shift the focus of services out of hospital, into the community and towards prevention, providing genuinely joined-up care and support.
The appalling standards of what passed for care in Mid Staffordshire and Winterbourne View were unacceptable and inexcusable. As the Francis Report and Serious Case Review into Winterbourne View make clear, the responsibility for this lies primarily with the providers.
Yet there is a deeper problem, which we ignore at our peril.
Too many people in both these hospitals did not need to be there, if they had been given the right support in the community or at home. Instead they went, or were sent, to institutions ill-equipped to deal with their complex blur of physical, mental and social needs.
This was not good for them, and it did not provide value for public money either. The average weekly fee for patients at Winterbourne View was £3,500 – rising to an astonishing £10,000 a week for one patient – for appalling, and in some cases criminally abusive, care.
The Government's approach
I don’t believe the Government’s reorganisation, or their other policies, will address these two fundamental challenges: giving real power to patients and the public, and radically reforming how and where care is provided.
Let me give you a couple of examples.
Patient and public involvement
The Government repeatedly claims Healthwatch will be a strong champion for users and the public in the NHS and social care: representing their views when local services are being developed, raising alarm bells if there are concerns about providers, and giving patients advice if things go wrong.
In reality, national Healthwatch simply doesn’t have the power and authority of the big three players in the system – the NHS Commissioning Board, Monitor and the Care Quality Commission.
It is not fully independent – it’s a sub-committee of the CQC – with nowhere near the same levers to pull, or incentives to use, to drive changes in the system.
Local Healthwatch will be equally weak and are barely off the starting bock in large parts of the country.
My recent survey found a third of councils cannot confirm they will have a fully functioning Healthwatch by 1st April this year.
Can you imagine if a third of Clinical Commissioning Groups weren’t going to be fully functioning by April? It simply would not have been allowed to happen, so why tolerate it for patients and the public?
The Government’s plans to put the experiences of individual patients at the heart of the NHS are also striking for their lack of vision and ambition.
I welcome the Friends and Family test, as far as it goes. However, it only asks whether patients would recommend an NHS service to others. It won’t explain the reasons for patients’ views, or provide the detailed, real time feedback on their experience of individual services that patients want, and staff need, to improve standards of care.
Robert Francis rightly said Mid Staffordshire hospital failed to listen to patients and that in future “there must be real involvement of patients and the public in all that is done.”
However, as Jeremy Taylor from National Voices – the national coalition of health and care organisations – says “Francis is strong on candour and weak on voice.”
Most of Francis’s recommendations focus on how to improve the system of monitoring, regulation and inspection in the NHS – unsurprisingly, since this was what he was asked to address.
Rigorous use of quality data, proper handling of complaints, a duty of candour, effective joined-up inspection, a system that genuinely holds doctors, nurses and managers to account – all these are crucial.
But these actions happen after the event, when what people really need is to prevent problems from happening in the first place.
We must seriously consider all of Francis’s recommendations whilst always remembering regulators can’t be everywhere, all the time. Patients and their families are, which is why their views and voices must be heard from the bedside to the Boardroom and at the heart of Whitehall too.
This Government’s policies also won’t achieve the transformation of services that everyone agrees is essential to meet the needs of our ageing population and the huge increase in long-term health conditions.
Einstein’s definition of madness is to keep doing the same thing over and over again but expecting a different result.
Yet this is precisely what the Government is doing.
Another NHS reorganisation, creating a plethora of new bodies. Attempting to bring these organisations together by giving them legal duties to co-operate and integrate, places on one another’s Boards, urging them to pool their separate budgets, and pilot more joined-up care.
If these were the right measures to deliver the scale and pace of change necessary, we’d have already achieved it – because they have been tried countless times before.
One of the problems of successive Governments has been a policy agenda that predominantly focuses on hospitals, rather than on the primary and community services that actually need to be transformed.
80 per cent of patients’ contact with the NHS is in primary and community care, and these services account for a quarter of the NHS budget.
So again, in rightly learning the lessons from Francis, we must ensure we don’t hit the target – improving hospital care, but miss the point – wherever possible keeping patients out of hospital in the first place.
So if this Government’s approach won’t secure the fundamental changes we need to build the new NHS, what is the alternative?
Choice and voice
I have been a long standing champion of giving patients and the public greater say and more control and I am proud of Labour’s record in Government.
We were the first to publish data on heart and stroke services, which was very controversial at the time but has made a huge difference in improving the quality of patient care.
We introduced Personal Budgets and Direct Payments to give people more control over their social care, linked patient experience to GP payments, created NHS Choices – and yes, gave people choice about their provider too, enshrining it in the NHS Constitution.
Some people criticise Labour for backing patient choice, saying what most people want is a good local hospital.
This is true. But what if your local hospital isn’t good?
A recent Freedom of Information request revealed that the number of patients who chose to go to Mid Staffordshire hospital through ‘Choose and Book’ fell from 15,700 in 2007/8 to 6,500 in 2012/13. In other words, almost two-thirds fewer patients chose to go to Mid Staffordshire in the space of 5 years.
Would anyone seriously want to have denied people this choice?
And can anyone who claims to stand “for the many, not the few” accept that when a doctor, or a member of their family, needs an operation, they can ask their peers which is the best hospital and who is the best consultant but deny this knowledge to ordinary members of the public?
So patient choice is essential. But for me, it has always been about far more than choosing which hospital or GP to use.
People want a whole range of choices about their treatment and care. They want to share decisions with health professionals for example about which medication to take, whether they should have surgery and what type of surgery.
Patients also want and need to take more control over their own health and care.
Technological developments are opening up huge opportunities to make this possible.
Last week I met Clive Calow, a constituent of mine who has COPD and diabetes.
Every morning he taps in answers to a series of questions on a computer screen by his bed about how he is feeling. He also takes his own blood pressure, oxygen levels, pulse and temperature using really simple technology, and then submits the results at the press of a button.
If there are any problems, his specialist nurse calls him up immediately to give him advice, such as whether he should take antibiotics or steroids. If the problem is serious, a rapid response team of ‘sprint nurses’ comes round to visit him in his flat and help stabilise his condition.
A year ago, Clive was on oxygen 16 hours a day and regularly ended up in hospital. Now, he is off the oxygen completely. Clive said his new care was “a god send” and his wife told me “it’s such a relief too”.
Evidence shows that patients who are actively involved in making healthcare decisions and in managing their own health have better outcomes than those who are passive receivers of care, and end up making less use of more expensive NHS care. The excellent care that patients with long term conditions like Clive get, must now become the norm.
We also need much more powerful ways of putting the experience of users and their families at the heart of the system.
Paul Jenkins, the Chief Executive of Rethink Mental Health recently wrote: “Major businesses like Tescos would be appalled at the low regard given by the NHS to the feedback it gets from its customers.”
With all the new technology that’s available, it doesn’t have to be this way.
There’s lots of really exciting developments in this area, like Patient Opinion and Care Opinion. These ‘TripAdvisor’ style servcies allow patients and users of adult social care to share their experience of services online, in writing or on the phone.
Patient and Care Opinion are really powerful tools for users to tell their story and find out what others have said about a service, and for local staff to get the feedback they need to tackle poor standards of care. They give people a voice and staff a powerful incentive to improve in a simple, easy and cost-effective way.
Detailed, real-time feedback like this must be an essential driver of change across all NHS and social care services in future.
Whole person care
However, it is still difficult to put users, families and the public at the heart of services when the system as a whole too often works against them.
In 1948, the World Health Organisation defined health as “a state of complete physical, mental and social wellbeing, not merely the absence of disease and infirmity”.
A simple vision, which stands today.
But for all its strengths, the NHS was not set up to achieve this.
We still have three essentially separate systems: physical health treated by the mainstream NHS, mental health on the margins, and social care provided through an entirely separate service of means tested council support.
For 65 years, we have just about made these three systems work for most people. But in the 21st century – the century of the ageing society – the gaps between these three services are becoming dangerous.
So when very elderly people with dementia end up in hospital, their mental and social needs can be neglected, which is why they often end up going quickly downhill.
People with mental health conditions often see their physical health needs overlooked, so those with serious problems die on average 15 years earlier.
And the growing crisis in social care means too many older and disabled people and their families face a desperate, daily struggle to the help they need to live with dignity and respect in their own home or in residential care.
That’s why, three weeks ago, Andy Burnham launched our health policy review – which I have been given the honour of leading.
The key question we are asking is: is it time for the full integration of health and social care? One budget, one service, co-ordinating all of a person’s needs: physical, mental and social. A service that starts with what people and their families want and is built around them.
So instead of constantly battling to make three separate systems work together – which users and staff are still trying to do after this Government’s reforms – we instead create a single system to achieve whole person care.
Making this vision a reality raises huge questions.
How do we commission for good health – including making the vital links with housing, education and employment – instead of continuing to commission predominantly for health services and individual diseases?
How do we get financial incentives in the right place – such as through a year of care budget – so services help people stay fit, healthy and living independently in their own homes?
Should district general hospitals evolve over time into fundamentally different organisations – integrated care providers from home to hospital – to finally shift the focus of services towards prevention?
What are the entitlements patients, users and the public might have – individually and collectively – in a fully integrated system?
One of the really important issues we need to look at is education and training.
We will always need doctors and nurses who can treat and cure individual diseases. But in an ageing society, with the huge increase in long-term, lifestyle related illnesses, NHS and social care staff must have the knowledge and skills they need to help people stay as healthy as possible, for as long as possible, and to manage their own health conditions.
As Andy said when he launched our policy review, we don’t yet have all the answers about how to make our vision of ‘whole person care’ a reality. We want and need to create the system together with users, the public and staff.
But we are clear: real change won’t come from an ever-tighter grip on an old fragmented, inward looking system. It will come by transforming the system so care is fully integrated, outward focused and shaped for and with users, families and the public. That is Labour’s vision of the new NHS.
Shadow health minister Liz Kendall - speech to "The New NHS' Reform conference 12 February 2013