An emergency shot in the arm for local health and care
In his first budget the chancellor should create strong incentives to spur innovation in primary and community health sectors. First, a dedicated £1bn investment and development fund, second, better mechanisms to share ‘what works’, and third, a consultation on statutory changes to make co-commissioning a reality. Only this level of central government commitment will give local politicians the steely determination to push through hospital reorganisation.
The NHS has on average received annual funding increases of 4% since it was founded in 1948. On a per capita basis from 2009/10 to 2019/20 spending will increase by less than 5%. But on an age weighted basis — taking into account the higher cost of our growing elderly population — real spending will actually decline.
Council spending on adult social care has been cut by almost 20% since 2009/10 and will continue to get squeezed. No wonder the airwaves, print and social media are dominated by the health and care crisis. The established model is no longer fit for purpose.
The 44 Sustainability and Transformation Plans (STPs) to resolve this are premised on reconfiguring hospital services — closing some — and integrating primary, community and social care so services can be delivered outside expensive hospitals and in or nearer people’s homes. However controversial that is the right policy direction.
But there is a flaw. The £5.3bn Better Care Fund to facilitate integrated health and care won’t provide the up-front supply side investment necessary to grow primary and social care provision. These sectors are already too fragile to take on additional capacity. Besides, the enormity of the NHS’s 2020 efficiency targets seem far too great for it to simultaneous reconfigure acute services and release cashable savings to develop capacity in the community. That challenge is even greater when you consider the UK already has low hospital bed numbers compared to similar developed countries.
In my local area, the North West London STP, Healthier Future programme, is based on over a decade’s experience of collaboration and integration across organisations. It includes plans to reduce the number of major hospitals from nine to five, but also accepts they are not supported by Hammersmith and Fulham RLBC or Ealing LBC. Local councillors just do not have confidence in top down transformation unless they can see credible local investment in primary and social care that will improve provision for their constituents.
Shouldn’t government invest in organisations to deliver the fundamental shift in provision from acute settings it advocates? Policy is only credible if backed up by the resources and capability to deliver it. In practice, this means capacity building investment in:
• integrated ‘super hubs’ with GP services, council funded care, and early years support;
• larger federations of general practice and ultimately fully integrated primary care companies that can offer a range of specialist services in the evening and weekends;
• community clinics so expert care be delivered outside hospital settings;
• and mission led care businesses delivering quality social care for the elderly and disabled.
The award winning CASA is a great example of the latter. It was established in 2004 with a mission to become the UK’s leading employee-owned provider of domiciliary health and social care services to older and disabled people. Since then it has quadrupled in size, with 750 employee owners and low staff turnover — a systemic challenge in the sector. That growth has taken time and was only possible with £0.4m of social investment.
The growth of networks of general practice is not new either. Brent’s GP Federation has grown into several consortia covering over a quarter of a million people, including the Harness GP Cooperative, a social enterprise established in 2006. These networks aim to deliver better patient care within available resources by sharing risk, focusing on population outcomes, and aligning incentives between providers and commissioners.
But by reinforcing the provider-commissioner split the Health and Social Care Act (2014) does not entirely support that process. Unless government makes changes to commissioning regulations, progress will be much slower than necessary.
The chancellor should use some of his windfall — borrowing is forecast at £12bn lower than target — to establish a £1bn time-limited, repayable investment fund. The fund should have the flexibility, patience and expertise to invest in primary and other local care businesses. It should be made up of a mixture of development grants and repayable capital that can be continually reinvested. Crucially the fund should be led by individuals with expertise in commercial and social investment, primary and social care.
Government officials could be involved on the board level to help set strategic direction and hold the fund to account for investment targets, including repaying the exchequer at least £0.5bn after ten years when it could be wound down.
Like most investors with a mission the fund would have an incentive to identify ‘what works’ so that it can make better investments. Too often valuable information on the impact of government transformation funding is not collected and shared on a systematic basis because it is not valued.
We urgently need more CASA’s, more networks of GP practices and the emergence of integrated primary care companies (as in the US and Europe); enterprises that have the mission and scale to deliver the broader range of services that STPs require to reduce acute capacity.
But they will need support and investment to get there. A revolving £1bn investment fund with development capacity would provide a shot in the arm for local health and care, and good value for the exchequer.
Making these changes will not solve the long-term challenge about how we should fund health and care, but they are within reach and could be taken now. What is really required is an honest national conversation with the public. But few politicians are willing to lead that debate.
Robert Pollock is a former Treasury official and director of the Public Service Transformation Network. The views expressed are his own.