David Fagleman is a Researcher and Adam Wildman is Research Manager at ResPublica.
The National Health Service is at critical juncture in its long and illustrious history. As our population becomes increasingly older and long-term chronic conditions more prevalent, our healthcare system must undergo a programme of serious service transformation in order to survive. At a time when health budgets have never been tighter, the next five years of health reform will be crucial.
The statistics make uncomfortable reading. Around 25 per cent of patients (15 million people) in England have a long-term condition, ranging from obesity and diabetes to cancer and dementia. Alone, these account for 70 per cent of the total NHS spend, 50 per cent of all GP appointments and 64 per cent of all hospital outpatient appointments. With an ageing population and tight fiscal conditions, the NHS faces a potential funding gap of £19 billion within ten years, and almost certain bankruptcy.
Established to combat acute conditions such as tuberculosis and polio, the NHS is simply not designed to treat modern complex conditions that require ongoing care outside of the hospital setting. Under its current structures, the NHS provides fractured and fragmented care that is detrimental to the patient and a drain on precious NHS resources, causing high levels of failure demand and increasing pressure on Accident & Emergency services.
Across the sector, there is widespread agreement that the solution to solving this crisis lies in organising healthcare in a much more integrated and holistic fashion. Doing so would not only deliver better health outcomes, but by moving to a more appropriate setting, produce cost-effective healthcare solutions.
Yet despite this apparent consensus, the move towards integrated care has been slow and marred with difficulties, most recently with through the cancelation of the £3.5 billlion Better Care Fund. In Power to the People: The mutual future of our National Health Service, which is being launched in Parliament today, we propose a model of healthcare commissioning that promotes enhanced service integration by embracing mutualism.
Mutuals are by their very nature democratic and benevolent organisations, and are perfectly placed to integrate the needs of patients with the capabilities of clinicians in an inclusive fashion. Further, existing as they do in a competitive environment, they would also improve the levels of competition for NHS services in the same fashion as the private sector, yet do so without excluding those patients that lack the means of accessing private medical insurance.
This move towards mutualism should not come as a great surprise. Mutuals already have a firm foothold in the NHS in the form of quasi-mutual foundation trusts and NHS spin-outs. But a mutual model has yet to be developed that can perform the integrating role required to deliver whole-person care. One type of mutual organisation that has often been ignored, but could perhaps perform such a vital role, is the friendly society (mutual associations that traditionally provide sickness benefits and life insurance).
The model we propose in Power to the People would be paid for out of current efficiency commitments established under the Quality, Innovation, Productivity, Prevention programme. CCGs would utilise the services of friendly societies, as prime contractors, for all those with long-term conditions in their area. The prime contractor model enables commissioners to access the expertise of a consortium of partners, each with a specific specialism, while only contracting out with a ‘prime’ contractor for the organisation of the whole care pathway.
The benefits of this model could potentially be vast. At the discretion of their GP, instead of a patient accessing a fractured system of care, NHS patients would access the services provided by the friendly society and their partners in an integrated pathway of care. This would reduce the strain that long-term conditions place on the NHS, and provide the patient with an efficient and simple pathway of care, undoubtedly provided in a more appropriate setting. Indeed, better service integration can produce a raft of savings. As discussed in a recent Monitor report, moving care to the most appropriate setting could save approximately £4.5 billion. Embracing mutualism could therefore not only save the NHS money, but improve health outcomes and improve patient satisfaction.
As part of this new system we also recommend that Monitor, the regulator for NHS England, be re-cast as the regulator for health service integration. Under the Health and Social Care Act, Monitor has a duty to “enable” integrated healthcare. But this only extends to allowing Monitor to intervene where providers are acting in a manner that is detrimental to the provision of integrated care. By re-casting Monitor to regulate NHS integration, the current passive approach to regulating integration will be replaced with a pro-active approach, ensuring that the move towards an integrated healthcare system becomes a reality. To enforce this, we recommend that Monitor produce Ofsted-like inspections and the grading of individual CCGs to encourage service integration.
We also recommend that the Department of Health reviews the Any Qualified Provider (AQP) initiative. Private providers that deliver NHS services do so under this programme, which permits them to provide basic NHS services including physiotherapy, dermatology and MRI scanning. Under AQP, services remain free to patients and patient choice has been increased. However, as the Government’s flagship scheme for increasing patient empowerment, it must allow for collaborative and integrated care.
The mutual model and recommendations laid out in our report provide solutions to achieving the integration of health services without adding any new structures and producing cost effective results. If the NHS is to remain free at the point of use, a move towards integrated care is imperative and should be the utmost priority for the Department of Health.