With less than six months to go to the general election the jostling for position is well underway. Labour have made it clear that they will centre their campaign on the NHS, which is certainly a sore point for the coalition government following the controversial Health and Social Care Act of 2012. Leading Labour’s charge for the NHS is Shadow Secretary of State for Health Andy Burnham, who has a long track record of working with the health service as health minister during Gordon Brown's premiership.
He's engaging, personable and certainly passionate about his brief but would his ideas, if put into action, be a magic cure for an NHS under stress? One of his key policy ideas is to give primary care commissioning to local authorities. They are already experienced commissioners of services and now with health and wellbeing boards (HWBs) there is a vehicle for this transfer of duties from clinical commissioning groups (CCGs) to councils. But where does this leave those GPs who put their heads above the parapet in the name of population-based care?
“While it's know we think the reorganisation has been a disaster overall there is always some good things that come from changes, and the greater levels of clinical involvement in commissioning is a good thing and it is something we would not want to lose,” says Burnham, maintaining that CCGs would stay under Labour but their role would 'evolve'.
Burnham says Labour's changes would be 'evolutionary'; a word invoked by former Secretary of State for Health Andrew Lansley, architect of the reforms, during the intense opposition to the Health and Social Care Bill, which was seen as revolutionary by many at the time.
Burnham, however, is talking about something “bigger than what is happening at the moment”.
“I am saying that if we are to rise to the challenge of the 21st Century we need to move from a medical model of commissioning to a broader social model of commissioning, where we link to all of those other things that determine health, particularly housing. That is a really important piece of alignment we need to build, because we want to have a system where the home is the default setting for care, not the hospital. So you have to start building homes with care in mind, and really aligning very cleverly and carefully health policy and housing policy at that locality level.
“The CCG remains; I am not saying the CCG goes. It will be asked to embrace a model of full integration, absolutely.”
Burnham is putting forward the idea that the CCG would act as the executive and the HWB as the non‑executive. This would allow the CCG to focus on service redesign, with the HWB taking a broader view of the community, linking health to housing, to planning, to leisure, to education, and in the end 'signing off' on any spending.
He thinks this could cut through the confusion created by the Act where CCGs were not given the primary care budget due to perceived issues around conflict of interest. This is currently being addressed by NHS England's co-commissioning agenda where CCGs are, to a greater or leasser extent, looking to take on the primary care budgets and therefore commissioning GP services as their primary care trust (PCT) predecessors did.
“If you go down the route that I am suggesting, where the health and wellbeing board is the overall sign-off body, you can consolidate the primary care budget under that umbrella. Underneath the HWB you consolidate the CCG budget, the local authority adult and children’s budget and the primary care budget. And arguably the CCG would have more influence over that bigger budget, but because the final sign-off is with the HWB you have taken away the conflict of interest question,” he says adding that the healthcare budget would be ringfenced.
This is all part of a 10-year plan for the NHS which Labour will publish in the coming months. Burnham wants the NHS and local government to work towards “a vision of a single-service, single-budget… an NHS for the whole person.”
“That would be a major, major change in terms of the way we think. One of the problems we have…when budgets are held in these separate silos… if you talk about a child with complex needs or a very vulnerable adult, you often get an argument between the NHS and local government about who is going to pay. And in fact that argument stops one of them doing the right thing, and the right thing is often intervening early.”
It’s Burnham’s hope that a single-budget approach will create the conditions for early intervention as savings will return to that budget and therefore bring back accountability.
He’s is also a big fan of the National Institute of Health and Care Excellence (NICE) and wants to increase its influence to tackle the 'postcode lottery'.
“I think one of my criticisms of CCGs is that we have seen the emergence of increasingly arbitrary restrictions on treatments out with NICE guidance. Restrictions on hip operations, knee operations, cataract operations, varicose veins,” he says citing the reasons for these restrictions as financial pressures.
“We have repeatedly challenged the government, who have said that they want to rule out rationing by cost, but we think it is still rife in the system. I want to be stronger about the N in NHS. We are going to reassert the authority of NICE. If NICE recommends something, everybody should get it everywhere. It should not be possible for local commissioners to say, ‘Do you know what? NICE have recommended it, but we are not going to do it.’ I just do not think that is right. People want the sense of a clearer entitlement to services. So if you are going to strengthen the N in NHS in that way, you obviously are protecting the NHS budget because you are saying that this is what people should get. But the thing that we are devolving is not what people get, but how it is delivered in every community.”
As well as moving commissioning to HWB and strengthening the impact of NICE's decisions, Labour would also seek to restore the democratic responsibilities of the Secretary of State to provide a full and comprehensive service. Would that spell the end of NHS England which was originally set up to make the service independent?
“I am going to work with the organisations I inherit,” says Burnham.
Burham wants to bring back the regional focus given by the strategic health authroities.
“I hear that some of the area teams are beginning to merge as they try to save money, but they are not yet over a regional basis and I think you need to bring back a regional planning function.
“I think NHS England has become a little unwieldy and has been trying to do too much, and that is why the primary care function I would devolve quickly right back to
He cites the example in his own constituency, where a practice team was waiting for a decision on a rebuild of a surgery.
“It is an area that had not had proper primary care for a long time; finally we developed a plan to rebuild a surgery, and it was an alternative provider medical services (APMS) contract. Though I have a lot of time for the officials at NHS England who have been looking at it, it feels to me that it has been sitting in a pile. This is the trouble with running primary care from a national level, is it not? You have a whole stack of things, too many cases, and you do not have that connection with the local area. So that has got to change. It really has to change urgently.”
So there are changes Burnham would make to NHS England but “the idea of keeping an NHS England that has an arms’ length relationship to the department is not necessarily a bad thing”.
Following the Labour Party Conference in September Burnham's plans to make hospitals integrated care organisations (ICOs) – a so-called hospital led model – hit the headlines and was anxiously received by those trying to wrestle care way from expensive hospitals.
Burnham explains that he wants the hospital to become responsible for those patients it sees on a regular episodic basis by coming out of their 'four walls' and treating such patients in their own home via a multidisciplinary team.
“We are today still running basically a hospital treatment model, the hospitals as the default setting for care, and it cannot carry on. It is not financially viable in the long run because hospitals are the most expensive end of the system, but it is not good for people either.”
He says that a consolidated budget at local level including both children and adult social care money will result in “something truly radical”.
“[We] can to start to build a Year of Care budget, not for everybody, but for vulnerable people with ongoing needs.
“So for people – either children with complex needs, adults with disabilities or frail elderly – there’s a Year of Care budget, or tariff you could call it. So this would be a massive evolution of payment by results, moving away from an episodic model or an activity model which, traps hospitals in a certain way of working, to a system that immediately switches the incentive from treating people in a hospital to supporting people preventatively in their home.”
The integrated care organisations is the way to manage this, he says.
“[Hospitals] grow out of the four walls and start thinking about home to hospital. That is something that they want, that they are starting to think about anyway.”
Burham also rules out the idea of making a challenge for party leadership.
“We have said as a party that the NHS is our priority going into the election, and I have a pretty big job to do to make a credible plan hang,” he said.
It seems Labour is keen to take the long view and is currently working on a vision covering the NHS from 2015 to 2025 and it is hoped that the detail of its health policy will be set down there. While it seems that CCGs will stay, one thing is certain – change.