ABHI Membership

The Friday Blog: The Future of Healthcare

I had a conversation with one of our members this week, who remarked that it had been a strange year on any number of levels. We were talking, primarily, about international trade, but he was not wrong. Most weeks are strange at the moment, and, now I come to think of it, so are the days. On Wednesday, Nextflix suggested that I might be interested in watching the Eurovision Song Contest, and each morning I awake to a phone full of “Recommendations” from Twitter, 95% of which I can make neither hide nor hair of. Not that I am too bothered, because by the time you read this, the froth will well and truly have been blown off the first one. I am doing what I keep telling you lot to do and being kind to myself by taking a fortnight off.

We are not going to be going far, I mean, why would you? The only reason I can think of for getting on an aeroplane right now is being a paratrooper. In order to try and retain some semblance of household harmony (two down, four to go) I have booked a couple of nights for dad and daughter at a cosy looking pub in the Ribble Valley. We have treated ourselves to new walking boots and a snazzy backpack, and will be exploring the foothills of the Pennines, from the right side of course, and the rolling fells of Bowland for the first time since I was a schoolboy. Beyond that, we will be doing what a lot of people have done and discovering the hidden historical gems and lesser travelled routes on our own doorstep. We will be creative about it too, by, for example, turning the annual visit of the MG for its MOT and service, into a cross city canal walk. I am not totally sure how we will dress up painting a newly plastered ceiling or building the latest instalment of IKEA furniture, mind. Some sort of drinking game I suppose.

Yesterday, Peter Ellingworth joined an elite band of 25 or so senior health leaders to hear Secretary of State Matt Hancock deliver an ambitiously titled “The Future of Healthcare” address in Regent’s Park at the Royal College of Physicians. If there was any doubt that we are moving away from the market-based approach to the delivery of healthcare, it was duly quashed. Of the seven lessons Hancock said health and care services have learnt during the pandemic, three were basically the same one repackaged to say the same thing about the future being one of collaboration, system working and the NHS opening its borders to others, notably Local Authorities. It was in the Five Year Forward View, it was in the Long Term Plan, and now it was here. We are moving inexorably to a place-based system of integrated care. He concluded with three themes, that power would be moved closer to the point at which services are delivered, accountability following, that unnecessary bureaucracy would be removed, a common theme of Conservatives the world over, and that there will be a real drive to the integration of health and social care.

To be honest with you, I was a bit underwhelmed. As we waiting for the event to start, (Hancock was a full, Rock Star like, twenty minutes late on stage), we were entertained on the RCP’s livestream service with some seriously funky jazz, whilst the screen played a collection of the College’s greatest hits on a loop that started out interesting, but got seriously tedious. My colleague Andrew Davies who, like me, was wondering if we had tuned into to the wrong gig, messaged me suggesting that the show was the political equivalent of foreplay. It was, actually, the Health Secretary’s speech itself that felt like foreplay to me, tantalising, offering promises of things yet to come but lacking anything of real substance. I was anticipating some clear statements of policy intent and an outline of the legislative programme needed to deliver it, but of that there was nothing, aside from a reference to needing to unpick the 2012 Act, pretty much as I described here last time. Hancock talked about this being the start of a conversation, but it is a conversation we have been having for decades. Other, less cynical commentators than I, may say at some point in the future, that Hancock’s great strength was Carpe Diem. It is easy to spot opportunities, but making the most of them is a different kettle of fish altogether. This time next year, Rodney, we will be millionaires.

The pandemic has certainly presented opportunities to improve care delivery, and many of them involve our sector. The one thing that Hancock did sate, was that all consultations should now be virtual, unless there was a valid clinical reason otherwise. It was one of another of his lessons, “Better Tech means Better Healthcare.” This has to be the easiest of wins. The lowest of low hanging fruit. We have never really used the telephone consistently to deliver care, having persisted with the large sheds attached to our hospitals we call Outpatients Departments. The pandemic has finally shown, beyond all doubt, that the vast majority of people can happily be dealt with remotely. The implications are potentially huge. Remote consultations improve productivity, reduce costs for patients and the NHS alike, and are a sustainable solution. I was once an outpatient at the Royal Free, and each appointment letter advised me not to even attempt to drive to the Hampstead site, such was the dearth of parking. Many of you will understand this better than I, as do NHS staff who regularly have their cars vandalised for daring to park, legally, in residential areas adjacent to their places of work when there are no on-site options.

Hancock made much of the fact that we must value and trust our people, giving them freedom to develop a culture of collaboration and change by “busting bureaucracy,” citing multiple requests from multiple regulators for the same information. But on how this was to be achieved, he was silent. He was silent, in fact on how any of it was to be achieved. I wondered, at points, why he had even bothered putting himself through delivering what was clearly a demanding keynote, and on which I would have scored him a six for delivery. He tried, to give him credit, and I am not sure I have ever heard a Conservative Minister quote George Orwell. (Road to Wigan Pier and the need to address social inequality). Maybe he had intended to make major announcements on giving Integrated Care Systems statutory body status, a sliming down of the regulatory framework and the integration of health and social care, but had his wings clipped by Downing Street, nervous about how the NHS will deal, simultaneously, with restart, whatever is next from COVID, flu season, winter pressures and Brexit.

We will see come September, when the Fun House returns, and we try and make sense of a hectic legislative programme ahead of the end of the EU exit Transition Period. But the signs are clear enough, Hancock made much of the co-terminosty of NHS organisations and Local health Authorities, and a local pound that is spent on the wider determinants of health on local populations. Intuitively, it should help us, one of the most significant and persistent barriers to the adoption of innovative technologies, is that investments in one part of the system realise benefits in another with no financial linkages between the two. In fact, there is no actual system. Until, maybe now, but it will need Integrated Care Systems that are actual systems, with legal status, not some sort of loose coalition of free-standing organisations relying on goodwill and the ability of people to get on with each other. We know how that goes.

The one thing that I am most hopeful for, but what will frighten everybody, not least Her Majesty’s Treasury, is the third of Hancock’s themes, driving the integration of health and social care. It is a conundrum. The NHS has about 140,000 beds and a budget of around £120 billion, there are 400,000 beds in the social care sector, and it has a budget of £22 billion. We charge people for social care but not, by and large, NHS services. Merging the two, albeit the intent of a Department named to include Social Care in 2018, will be tricky, but the prize is immense. The place where our acute hospital system falls down most completely, is where it interfaces with the social care sector. Those 400,000 beds are filled with the frail elderly, and the sector lacks the capability and capacity to look after them properly. Invariably, the frail elderly then present, avoidably, to the most resource intense part of the NHS, Accident and Emergency, from where they are admitted. Once admitted, it is difficult to discharge people back to a system that has demonstrated it cannot look after them. The result is bed blocking. Some more enlightened acute hospitals have figured this out and have deployed their own staff into the care sector. Done well, it frees up A&E and protects bed capacity for elective work. It is also better for patients, not least because it has the potential to transform that critical interface, release resources and avoid the situation we have found ourselves in whereby people have to sell their homes to pay care bills. Hancock’s aspiration is for every citizen to have access to the care they need, whenever and wherever they need it. The political prize is equally immense. The NHS is Labour’s proudest achievement, the service and the Party are inextricably linked. The Tories, not unreasonably, make the point that the NHS has been under their stewardship for longer than that of the Labour Party, and has flourished during that time. It is a message they have failed to land. But what if now they can deliver something as fundamental as a move towards equity in the provision of care, as the foundation of NHS itself? 70 years of being on the back foot is reversed. It would also be the right thing to do.

It may be something of an aside, but my favourite quote of the speech was “healthcare is a risk-based business.” I sense this is something we will play back to the Health Secretary and others as we consider what the future regulation of our sector might look like.

Elsewhere in central government it all got a bit Yes Minister again, with the announcement that No. 10 is advertising for a spokesperson to front new televised White House-style press briefings. It is either a major move towards more open government or a ham-fisted attempt to protect the PM from difficult questions asked by the media pack. Answers on a postcard. But if you fancy it, and it has a six-figure salary attached, you better get used to saying, “What the Prime Minister meant to say, was…” You may also want to have your groceries delivered for a while. I do not suppose that the decision to post the ad had anything to do with the fact that the next day Boris received a kicking from the Office for Statistics Regulation. The PM has been bigging up his Government’s record on reducing child poverty, but strayed into lies, damned lies and statistics territory. The End Child Poverty Coalition complained that official figures had been used “selectively, inaccurately and, ultimately, misleadingly.” Ouch! But hey, get your application in, and it could be you on the receiving end of official reprimands and taking many for Team Boris. A seat in the Lords doubtless awaits.

Be sure to check out our COVID resource page this week, which has been updated to include details of an extension to the CBILS.

So that is me for a couple of weeks, and I will be leaving you in the very capable hands of our friends at PB Political Consulting, who will be looking ahead at a busy autumn of legislation and how the Government might want to exert more control over its arms’ length bodies. Enjoy your summers safely.